13th AFSM Proceedings - UMEXPERT · MEDIMOND InternatIonal ProceedIngs M EDIMOND - Monduzzi Editore International Proceedings Division 13th AFSM Proceedings 25th-28th September 2013

MEDIMONDInternatIonal ProceedIngs

MED

IMON

D - M

ondu

zzi E

dito

re In

tern

atio

nal P

roce

edin

gs D

ivis

ion

13th AFSM Proceedings

25th-28th September 2013 Kuala Lumpur, Malaysia

Editor

Prof. Dr. John George

© Copyright 2013 by MEDIMOND s.r.l.Via G. Verdi 15/1, 40065 Pianoro (Bologna), Italy

www.medimond.com • [email protected]

All rights reserved. No part of this publication may be reproduced,stored in a retrieval system, or transmitted, in any form,or by any means, electronic, mechanical, photocopying,

recording or otherwise, without the prior permission,in writing, from the publisher.

Printed in December 2013 by Editografica • Bologna (Italy)

ISBN 978-88-7587-691-3

is a registered trademark owned by Medimond s.r.l.

monduzzi editoreInternatIonal ProceedIngs dIvIsIon

©2013 MEDIMOND III

Foreword

This E book contains Extended Abstracts and Full Papers of some of the topics presented at the 13th Asian Federation of Sports Medicine Meeting in Kuala Lumpur, Malaysia from 26th to 28th September 2013.

Prof. Dr. John GeorgeChairman, 13th Asian Federation of

Sports Medicine Congress

The Honorable Minister of Youth and Sports, Khairy Jamaluddin (second from right) visiting the booths after the official opening ceremony of the 13th AFSM Congress held in Kuala Lumpur. He is flanked on the right by the Chairman of the Congress and President of Malaysian Association of Sports Medicine, Professor Dr John George and on the left by the

CEO of the National Sports Institute of Malaysia, Datuk Dr Ramlan bin Aziz who was also Chief Advisor of the Congress.

© Medimond III

Index

Exercise-Induced Oxidative Stress in the Heat: Do Nutritional Supplements with Antioxidant Properties Help? Chee Keong Chen.............................................................................................................................................. 1

Comparative effectiveness of ultrasound guided intratendinous Prolotherapy injection with conventional treatment to treat focal supraspinatus tendinosis : randomised control study George J., Ch’ng Ls., Jaafar Z., Hamid Msa,.................................................................................................. 3

Sports Radiology : Making a diagnosis or solving a problem George J.............................................................................................................................................................. 9

“Duty of Care, Roles and Responsibilities of a practitioner working in the sporting environment” Hodgson L. ......................................................................................................................................................... 19

Promotion of health related physical fitness of people with intellectual disabilities Inal H.S. ............................................................................................................................................................... 23

Integrating physical, mental, emotional and energy components into athletes’ lifestyle to ensure athletic excellence and health Lal P.R., Balakrishnan B. .................................................................................................................................. 25

Applications of salivary biomarker measures in sport science McKune A.J. ....................................................................................................................................................... 39

The eye in sporting activities Ong K................................................................................................................................................................... 43

Platelet-rich plasma: Facts and fallacies. Shariff A.H........................................................................................................................................................... 47

Ramadan and Sports Performance Singh R................................................................................................................................................................ 51

Obesity, physical activity among subjects with Intellectual Disabilities: Considerations to promote of the level of Physical activity Subasi F. ............................................................................................................................................................. 55

What is Special about Special Olympics? Opportunities for Sports and Fitness for People with Intellectual Disability Toh TH, Mah LHK............................................................................................................................................... 59

The reliability of functional movement screen tm ( fms tm ) in the healthy young men Maeda N., Urabe Y., Fujii E., Shinohara H., Sasadai J., Moriyama N., Kotoshiba S., Yamamoto T........ 65

© Medimond IV

The Effects of Changes in Rules and Regulations on Sepaktakraw Match Performance Nagahama H., Kubo Y., Sasaki S..................................................................................................................... 69

Resitance exercise with blood flow restriction in women Okita K., Takada S., Suga T., Kadoguchi T., Taniura T., Morita N., Yokota T., Kinugawa S., Tsutsui H............................................................................................................................................................. 73

Ultrasonographic measurement of the posterior ankle region at various plantar flexion angles Sasadai J., Urabe Y., Maeda N., Fujii E., Shinohara H. ................................................................................. 77

Influence of Difference in Knee Alignment on Site of Pain after Walking Sogabe A............................................................................................................................................................. 81

Psycho-Social Factors Promoting Psychological Acceptance of Athletic Injuries Tatsumi T., Takenouchi T. ................................................................................................................................ 87

Association between altered pelvic tilt and hamstring strain among rugby palyers (case in kandy district, Sri Lanka) Wickramasinghe Y.M.N.M, Buddhika W.H.S.W.R, Paththuwage R.G, Weerasinghe W.C.S, Wijayalath W.P.L.K, Udyakumari A.D.M. ........................................................................................................ 91

The effects of musical tempo during cycling exercise among undergraduate sport science students Illias N.F., Adnan R., Ross V., Sulaiman N., Appukutty M. .......................................................................... 95

Acute changes in blood pressure after physical activities Raja Yong S., Lee C.P., Moganan M., Misran M.H.I....................................................................................... 107

Explain the income strategies of sport clubs from view point of Tehran sport managers Pirmohammadi M., Omidzade Monfared M., Dehghani S. ........................................................................... 111

13th Asian Federation of Sports Medicine Congress - AFSM (September 25-28, 2013, Kuala Lumpur, Malaysia)

© Medimond . Q926R9007 1

Exercise-Induced Oxidative Stress in the Heat: Do Nutritional Supplements with Antioxidant Properties Help?

Chee Keong Chen

Sports Science Unit, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia Correspondence Address: Sports Science Unit, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia E-mail address : [email protected] - Telephone number : +609 7676 933 Fax Number : +609 7641 945 Section : Sports Science Sub-Section: Sports Nutrition

Oxidative stress occurs when the rate of production of free radicals exceed the body’s antioxidant capacity to detoxify them (1, 2). Free radicals refer to reactive oxygen species (ROS) and reactive nitrogen species (RNS) which are highly reactive because of an unpaired valence electron. Examples of frequently cited free radicals include superoxide, hydrogen peroxide, hydroxyl, nitric oxide and peroxyl (3, 4). ROS have been associated with cellular differentiation, ageing, mutagenesis, carcinogenesis, pathophysiology of numerous diseases and muscle soreness and damage during exercise (1, 5). Exercise-induced oxidative stress has been demonstrated in several studies (2, 6, 7). For instance, significant increases in F2 isoprostanes and lipid hydroperoxides following exhaustive exercise substantiates that exercise induces ROS production (8).

Besides exercise, hyperthermia has been shown to increase oxidative stress in vitro but has not been adequately assessed in humans in vivo (9). However, Ryan et al. (10) reported that a body core temperature greater than 40oC increased heat shock protein expression in leukocytes obtained from exercising individuals. Increased core temperature may increase or contribute to radical formation by uncoupling the mitochondrial respiratory chain or inhibiting or overwhelming the antioxidant defense mechanism (11, 12). Futhermore, McAnulty et al. (13) showed that hyperthermia (rectal temperature of 39.5oC) also enhances oxidative stress in subjects who ran on a treadmill for 50 min in the heat. Hence, the potential relationship between hyperthermia and ROS is vital due to the significant heat load that can be generated during exercise. This heat load arises from increased metabolic heat production and exercise in conditions of high heat and humidity.

Oxidative stress is thought to be involved in muscle soreness and damage during exercise (14). The mechanism by which free radicals induce muscular fatigue remains unclear. However, some investigators have postulated that free radicals might damage the sarcoplasmic reticulum resulting in reduced calcium release during depolarisation of the muscle (15, 16) and consequently lead to decreased muscle performance and muscular fatigue (17, 18). Nitric oxide has also been suggested to have a direct inhibitory effect on contractility in muscle fibres (19).

The effect of antioxidant supplementation has been suggested as a means of improving skeletal muscle performance and reducing oxidative stress during exercise (20, 21). Antioxidants are among the most common sports supplements taken by amateur and professional athletes (22). Most studies to date however, have not shown any beneficial effect of antioxidant supplementation directly or consuming diets containing large quantity of antioxidants (20). The studies that have shown positive effects of antioxidants on skeletal muscle endurance performance were continuous administration of N-acetylcysteine via venous infusion during exercise (23, 24). In addition, two other studies with pycnogenol supplementation also demonstrated that endurance performance was improved following acute (25) and 30 days supplementation (26).

We have also carried out several studies on the effects of various nutritional supplements with antioxidant properties on endurance performance in the heat. These supplements include palm vitamin E, caffeine, panax gingseng, Eurycoma Longifolia Jack (Tongkat Ali) and honey. The results of these studies are as follow: 1) Tocotrienol-rich palm vitamin E supplementation decreased lipid peroxidation at rest, and to a certain extent, during exercise in the heat, as evident from the lower plasma malondialdehyde levels. However, palm vitamin E at a dosage of 360 mg.day-1 for 6 weeks did not enhance endurance running performance or prevent muscle damage during exercise in the heat (27); 2) Ingestion of 5 mg of caffeine per kg body weight an hour prior to exercise improved the endurance running performance in recreational runners in a hot and humid



environment (28); 3) Acute supplementation of 200 mg of Panax gingseng consumed an hour prior to the exercise session did not affect endurance running capacity in heat-adapted recreational runners in the heat (29); 4) Supplementation of Eurycoma Longifolia Jack at a dosage of 150 mg.day-1 for 7 days did not seem to improve endurance running performance in recreational athletes in the heat (30); 5) Consuming Acacia honey drink at 3ml per kg. body weight every 20 minutes had similar beneficial effect in improving endurance running performance among recreational athletes in the heat compared with a commercially available sports drink (31).

In summary, supplementation of palm vitamin E, Panax ginseng and Eurycoma Longifolia Jack did not seem to have any beneficial effect on sports performance in the heat. However, more studies with different dosages and duration of supplementation are warranted to confirm these observations. On the other hand, we have demonstrated that caffeine and honey drink may have ergogenic effect on endurance performance in the heat. Nevertheless, future studies are necessary to substantiate these findings and to identify the precise mechanisms underlying the observed effects.

References

1. Sjodin B, Hellsten-Westing Y, Apple FS. Sports Med 1990; 10(4):236-254. 2. Marzatico F, Pansarasa O, Bertorelli L et al. J. Sports Med Phys Fitness 1997; 37(4):235-239. 3. Holley AE, Cheseeman KH. British Med Bull 1993; 49(3):494-505. 4. Boveris A, Cadenas E. IUBMB Life 2000; 50(4-5):245-250. 5. Vina J, Gomez-Cabrera MC, Lloret A et al. IUBMB Life 2000; 50(4-5):271-277. 6. Li JX, Tong CW, Xu DQ et al. Eur. J Appl Physiol 1999; 80(2):113-117. 7. McAnulty SR, McAnulty LS, Nieman DC et al. Free Radic Res 2003; 37(8):835-840. 8. Nieman DC, Henson D, McAnulty SR et al. J Appl Physiol 2002; 92(2):1970-1977. 9. Flanagan SW, Moseley P, Buettner GR. FEBS Letters 1998; 431:285-286 10. Ryan AJ, Gisolfi CV, Mosely PL. et al. J Appl Physiol 1991; 70:466-471. 11. Brooks GA, Hittleman KJ, Faulkner JA et al. Am J Physiol 1971; 221:427-431. 12. Hass MA, Massaro D. J Biol Chen 1988; 263:776-781. 13. McAnulty SR, McAnulty L, Pascoe DD et al. Int J Sports Med 2005; 26(3):188-192. 14. Finaud J, Lac G, Filaire E. Sports Med 2006; 36(4):327-358. 15. Davies KJA, Quintanilha AT, Brooks GA et al. Biochem Biophys Res Commun 1982; 107(4):1198-1205. 16. Lovlin R, Cottle W, Pyke I et al. Eur J Appl Physiol 1987; 56(3):313-316. 17. Shindoh C, DiMarco A, Thomas A et al. J Appl Physiol 1990; 68(5):2107-2113. 18. Barclay JK, Hansel M. Can J Physiol Pharmacol 1991; 69(2):279-284. 19. Kobzik L, Reid MB, Bredt Ds et al. Nature 1994; 372:546-548. 20. Peake JM, Sizuki K, Coombes JS. J Nutr Biochem 2007; 18:357-371. 21. Reid MB. Free Radic Biol Med 2008; 44: 169-179. 22. Braun H, Koehler K, Geyer H et al. Int J Sport Nutr Exerc Metab 2009; 19:97-109. 23. Medved I, Brown MJ, Bjorksten AR et al. J Appl Physiol 2004a; 96:211-217. 24. Medved I, Brown MJ, Bjorksten AR et al. J Appl Physiol 2004b; 97:1477-1485. 25. Bentley DJ, Dank S, Coupland R et al. Res Sports Med 2012; 20:1-12. 26. Pavlovic P. Eur Bull Drug Res 1999; 7:26-29. 27. Keong CC, Singh HJ, Singh R. J Sports Sci Med 2006; 5:629-639. 28. Ping WC, Keong CC, Bandyopadhyay A. Indian J Med Res 2010; 132:36-41. 29. Ping FWC, Keong CC, Bandyopadhyay A. Indian J Med Res 2011; 133:96-102. 30. Muhamad AS, Keong CC, Kiew OF, Abdullah MR, Lam CK. Intl J Appl Sports Sci 2010; 22(2):1-19 31. Sukri MN, Ooi FK, Chen CK, Sirajudeen KNS. Proceedings: 16th National Conference on Medical and

Health Sciences, School of Medical Sciences, Universiti Sains Malaysia ISBN: 978-967-5651-03-8, 2011; 217-224.



Comparative effectiveness of ultrasound guided intratendinous Prolotherapy injection with conventional treatment to treat focal supraspinatus tendinosis : randomised control study

George J. 1,2, Ch’ng Ls. 1, Jaafar Z. 3, Hamid Msa3

1University of Malaya Research Imaging Centre, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Departments of 2Biomedical Imaging and 3Sports Medicine, Faculty of Medicine, University Malaya Medical Center, 50603 Kuala Lumpur, Malaysia.

Summary

Even though supraspinatus tendinosis is a common problem, there is not much literature on treatment of supraspinator tendinosis with direct tendon injectables compared to tendinosis compared to other sites such as lateral epicondylitis. This study aims to determine the efficacy of dextrose prolotherapy injection for focal supraspinatus rotator cuff tendinosis via ultrasound parameters and functional score. Prolotherapy group show significant improvement in abduction (p=0.030). No significant improvement in functional score after 12 weeks was seen between both groups (p=0.364). Pain reduction was 57.1% in injection group and 25% in control group. 71.4% of patients in the prolotherapy have improvement in sleep (p=0.027). The intensity of area of tendinosis increased with treatment (p=0.009). However no significant difference in intensity change of tendinosis was noted between the two groups (p=0.927). Compared to conventional physiotherapy management, ultrasound guided intratendinous prolotherapy injections significantly improved range of abduction, reduced pain and improved sleep within 12 weeks.

Introduction

Shoulder pain is an important condition of the upper extremity occurring in approximately 15/1000 patients per year in the outpatient primary care setting. Currently the known regenerative injection-based therapies which have been used in supraspinatus and other tendinosis, in particularly lateral epicondylitis are : Platelet rich plasma (PRP), Autologous Blood and Prolotherapy. Types of prolotherapy include dextrose, phenolglycerine-glucose (P2G) and sodium morrhuate. The objective of this study is to study the role of dextrose prolotherapy and the ultrasound changes pre- and post-injection.

Materials and Methods

12 patients participated in this randomised controlled prospective study and were randomly divided into two groups (7 patients in prolotherapy group and 5 patients in control group). Inclusion criteria included focal supraspinatus tendinosis confirmed on ultrasound and failure of functional score to improve more than 30% after 1 month of conventional treatment after first attendance to our sports medicine outpatient clinic. Exclusion criteria included mechanical cause of shoulder pain, full-thickness tendon tears, autoimmune diseases, patients on anticoagulant, congenital or acquired platelet dysfunction abnormality/disorder, haemoglobin level less than 10g/L and/or platelet count less than 100,000/uL, corticosteroid injection within the past 6 weeks and self-reported immuno-compromised status.

Functional score using the Disability of Arm and Shoulder (DASH) Score and physical examination for range of shoulder movement were performed by the sports medicine physician at recruitment to study and after 12 weeks.

Patients in the prolotherapy treatment group were seen and treated with 1 to 2 injections of 0.5 to 1ml mixture of 12.5% Dextrose Solution and 0.5% Lignocaine in bacteriostatic water into area of painful focal



tendinosis under ultrasound guidance at one week interval according to relieve of symptoms. Patients in both groups continued to get standardised physiotherapy regime and mechanical loading for 12 weeks.

Ultrasound parameters assessed were such as intensity area of tendinosis (dB), area of tendinosis on cross section (mm2), length of partial tears (if present), presence of calcification, periostitis of adjacent greater tuberosity , doppler flow within area of focal tendinosis, subacromial bursitis and dynamic impingement.

Figure 1 Longitudinal sonographic image obtained using 5-17–MHz linear array transducer after insertion of 21-gauge needle shows tip of needle located in area of tendinosis with prolotherapy injected (*).

Results

There were 14.3% (1 patient) of patients in prolotherapy group and 40% (2 patients) of patients in control group who show significant improvement at 12 weeks(Table 1). There was no significant difference in the improvement of functional score between these 2 groups using the Fisher-Exact test (p=0.364).

There were 57.1% of patients in prolotherapy group who showed significant reduction in pain score while in the control group was 25% (Table 1). However, there was no significant difference of pain score in both groups using the Fisher-Exact test and p value was 0.247. There was significant difference in sleep improvement between both groups using the Fisher-Exact test and p value was 0.027 (Table 1). 62.5% of patients in prolotherapy group improved in sleep score while no patients improved in the control group.

There was significant improvement in shoulder abduction in prolotherapy patients compared to the control group using Mann-Whitney U Test with p value of 0.030. Range of abduction of patients in the prolotherapy group increased with a mean of 20.0⁰ while the mean range of patients in the control group decreased with a mean of 12.0⁰ (Figure 2).



Figure 2 Boxplot comparing difference in degree of abduction between prolotherapy and control group at baseline and at 12 weeks (p value = 0.030).

Table 1 Comparison DASH, pain and difficulty to sleep between prolotherapy and control group at baseline and at 12 weeks.

Mean

Baseline 12 weeks Significant Improvement (%)

P-value (Fisher-Exact)

DASH Score Prolotherapy Control

60.14 56.86

43.89 46.68

14.3% 40.0%

0.364

Pain Score Prolotherapy Control

3.29 3.20

1.86 2.40

57.1% 20.0%

0.247

Difficulty to Sleep Score Prolotherapy Control

3.29 2.20

2.15 2.60

71.4% 0.0%

0.027

There was no significant difference in improvement of the ratio intensity of tendinosis to normal tendon from baseline to 12 weeks between both groups using the Mann-Whitney U and p value was 0.93. However, there was significant increase in the intensity of the area of tendinosis from baseline and at 12 weeks when both groups are combined using Mann-Whitney U and p value was 0.009 (Figure 3).

The other ultrasound parameters did not show significant difference between the prolotherapy and control group. There were also no significant correlation between ultrasound parameters with functional and pain score.



Figure 3 Intensity measurement of tendinosis (a) and normal tendon (b) at baseline which was 5.56 dB and 19.50 dB respectively giving a ratio of 0.26.Intensity measurement of tendinosis (c) and normal tendon (d) at 12 weeks after injection which was 20.07 dB and 28.97 dB respectively giving a ratio of 0.70 which showed increase in ratio. Transverse sonographic image of the supraspinatus tendon at baseline (a, b) and at 12 weeks (c, d) at same section showing almost similar humeral head diameter (+). The tendinosis measured with continuous trace (b) on cross section is almost not visible at 12 weeks (d) marked with (*).

Discussion

There is significant reduction of pain score in prolotherapy patients with improvement of movement such as abduction. In a study on prolotherapy in knee osteoarthritis, there were similar results which was 40% decrease in pain post 12 months dextrose prolotherapy injections and improvement of movement which is flexion of 14⁰. (1, 2). In our study with reduction of pain particularly in the prolotherapy group, these patients were able to lie on affected shoulder during sleep and thus sleep is improved. Prolotherapy improve sleep and therefore will improve quality of life of patients.

Significant improvement in abduction was noted in prolotherapy patients compared to the control group. Movement is very important for patients in activities of daily living. A simple action such as flicking on a light switch will be made possible with improvement of abduction and forward flexion.

Increase of intensity of tendinosis in both groups regardless of treatment, suggest area of tendinosis regional intensity measurements of the hypoechoic abnormal tendon increases to near similar normal intensity with treatment in both groups. This suggests remodeling of the tendon. A study on autologous blood injection for lateral epicondylitis showed the median echogenicity of the tendon significantly increased to near normal-like tendon appearance as well(3).

There is no significant correlation of ultrasound parameters and function. Zeisig et al (4) and Connell et al (3) also reported decreased structural defects on ultrasound, though these were not reliably correlated with clinical gains.

Conclusion

Dextrose prolotherapy was clinically effective and safe in the treatment of pain with joint movement limitation. It is advocated for patients who want faster improvement in shoulder abduction, pain and improvement in sleep. We hope our study forms the base for earlier intervention and not waiting for conditions to be deemed recalcitrant which is usually after 4-6 months of conventional therapy.



Trial Registration

Study is registered under Current Controlled Trials (UK) and given International Standard Randomised Controlled Trial Number (ISRCTN) of 43520960.

Acknowledgement

This research was funded by Post Graduate Research grant (PPP) Grant No. P0155/2010B of University of Malaya.

Input on the statistical analysis of this research by Dr Mohammad Nazri Bin Md Shah and Dr Yeong Chai Hong, lecturers at University Malaya were much appreciated.

Reference

1. Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Altern Ther Health Med. 2000 Mar;6(2):68-74, 7-80.

2. Reeves KD, Hassanein K. Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of clinical efficacy. J Altern Complement Med. 2000 Aug;6(4):311-20.

3. Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol. 2006 Jun;35(6):371-7.

4. Zeisig E, Ohberg L, Alfredson H. Sclerosing polidocanol injections in chronic painful tennis elbow-promising results in a pilot study. Knee Surg Sports Traumatol Arthrosc. 2006 Nov;14(11):1218-24.



Sports Radiology : Making a diagnosis or solving a problem

George J.

University of Malaya Research Imaging Centre University of Malaya Medical Centre Kuala Lumpur , Malaysia .

Aim:

A Musculoskeletal Radiologist who images Sports Injuries has a major role of detecting the cause of the patients current symptoms which is their current problem which affects their performance and quality of life .

Methodology : The skill needed to do the above must be acquired from basic training as a resident, speciality training in Musculoskeletal Radiology, attendance at Basic and Advanced Courses in MSK and then Clinical attachments . Radiology research should be directed at problem solving .

Results: Basic Training should be by rotation to speciality rather than modality approach as the author has found accuracy of reporting significant abnormality in joints is only around 50% for those trained by modality approach. Subspecialty training should depend on a log of cases done rather than duration alone. Radiology research at UMMC has contributed to cartilage injury detection and mapping of injuries more accurately .

Conclusion: With use of directed questions, limited physical examination , dedicated rotation under Musculoskeletal MRI and Ultrasound specialists and applying useful research findings and protocols it is possible to solve the patients current problem rather than just make a diagnosis.

Text:

Basic Training in Musculoskeletal Radiology during Residency

In an International Musculoskeletal MRI and Ultrasound Course held in Malaysia with myself as Course Director , homework of actual MRI video cases is given for knee and shoulder examination reveals accuracy of only about 50% in reporting significant pathology including meniscal tears of the knee. When questioned the radiologists with such results all mention being trained in a modality approach where they are attached to the MRI unit doing all sorts of different scans and not attached under a musculoskeletal radiologist for a two or three months.

A good example of specialty based training is in the Leicester Based Radiology system where the training is by rotations from first to third year in specialty based training. The summary of their training can be found at https://www.eastmidlandsdeanery.nhs.uk/page.php?id=829). Speciality based training is also used in Dubai and website link is as follows: http://www.dha.gov.ae/EN/SectorsDirectorates/Directorates/MedicalEducation/Services/ResidencyProgram/Documents/Radiology.pdf

Additionally , it is useful to have some sessions where the trainee radiologists can join the orthopaedic clinic or rheumatology clinic to witness the physical examination being done will help in doing stress tests to joints while performing ultrasound and improving diagnostic accuracy. This is particularly important in the ankle examination as the stress tests will help delineate the ligaments such as the CFL much better and avoid erroneous reports

Subspecialty training and Clinical attachments:

This must be done today in a centre with both training in Musculoskeletal MRI and Ultrasound . Gone are the days when one can call themselves a Musculoskeletal Radiologist with just Musculoskeletal MRI training. Musculoskeletal Ultrasound is now widely accepted to be able to accurately diagnose much of the Musculoskeletal pathology especially of superficial ligaments and structures more accurately .



For Musculoskeletal MRI - the use of the correct technology is also important to enable to get the necessary information . For instance the MRI machine should preferably be a 1.5 T or higher specification . It is important to note that not all 1.5 T magnets are of the same quality. One of the ways to assess a good quality MRI is that it is able to resolve the femoral weight bearing cartilage of the knee which is just 3 to 4mm and pick up 1-2mm loss of thickness.

A centre where Orthopaedic Surgeons regularly do arthroscopic surgery is preferred and give feedback to the Musculoskeletal Radiologist helps to improve accuracy .

The training period to learn MSK MRI and Ultrasound for a Clinical Attachment should not be less than 3 months for Clinical Attachment and one year for a proper fellowship. It is important that this time be divided into Observation, doing the provisional report or initial ultrasound of the patient under supervision which is then checked and finally doing ultrasound scans on your own in a second room and getting the Consultant to come and check the scans. Formal assessment should be performed before one is allowed to scan and interpret on their own.

A Clinical Attachment or doing scans without a superviser or instructor is not beneficial as there is lack of feedback.

Attending Basic and Advanced Course in Musculoskeletal MRI and Ultrasound.

Continous Professional Education requires individuals to attend course preferably which don’t just have lectures but also run actual cases of all common pathology which should not be missed .

In the Penang MSK MRI and Ultrasound course of which I am Course Director (www.penangmskrad.com) MSK MRI videos and MSK Ultrasound Videos demonstrating the MRI and Ultrasound principles learned during the lectures are shown to bring home the salient points.

The courses should not have more than 1 demonstrator to 6 pax at one ultrasound table and the ultrasound machines should be of high resolution . There should be at least 2 hours of hands on musculoskeletal ultrasound time per joint or forearm etc. If possible Video CD of the procedures showing how each region is done should be shown to the delegates before the ultrasound session and the common pathology after the practical session so the delegates can recognise the normal images and planes before being shown the videos.

Course materials will usually include some of the up to date articles references and E books and powerpoints which have been released by speaker for open usage .

The emphasis in the lectures and practical sessions during the course will be on the types of questions that should be asked , how to select the right imaging modality , showing the simple stress tests and best positioning for detection of abnormalities.

Musculoskeletal Ultrasound allows one to examine the exact point of point tenderness and to look at the underlying structure that is the source of the current symptoms of the patient and get this treated.

Continous research and publications to add new insights, techniques and transfer knowledge.

Scouring the internet for recent articles especially review articles and reading them after a solid course is to be encouraged. After a solid course many of the images that are in the articles and the text will come alive and make sense and will form the basis of covering areas that you may want further materials or explanation not possible to cover in a short course. New techniques can be studied and applied.

Some examples of problem solving with original research at UMMC include a. Diagnosis of anterolateral menisco –capsular tear which may explain joint line lateral joint line

tenderness which is not associated with a meniscal tear. (1) b. Researching cartilage protocols which can detect 1mm cartilage defects and internal cartilage

changes before loss of thickness. (Use of CISS 3D sequence Siemens or equivalent) . Background research is quite adequate in the literature ( 2,3,4,5)

b. Treatment of focal supraspinatus tendinosis with dextrose prolotherapy . to hasten improvement of clinical symptoms and function.

C. Grading of Tendinosis - so that appropriate treatments can be instituted a. focal tendinosis b. Tendinosis complicated with calcification and or tear c. Partial tear or full thickness tears d. Bursitis e. Tenosynovitis Each of the above needs specific treatment whether it be conservative or with some intervention.



Here are some examples of methodologies used at UMMC as part of original work to help solve problems .

Problem: More accurate delineation of cartilage defect up to 1mm in weight bearing area of the knee and then classification of the region to make it easier for the arthroscopist to find the lesion.

A thesis project in UMMC was done addressing the above issue.

The Methodology was as follows:

Selection and preparation of tissue samples for MR imaging

3 types of tissue samples were selected from the osteochondral specimens to be included in the study: i) The first type of tissue samples consist of normal cartilage. They are white in appearance on gross

pathology and there is no evidence of fibrillation or loss of height of cartilage. ii) The second type of tissue samples consist of abnormal cartilage which the thickness is preserved

but the cartilage appears less white (discoloured) and soft on probing. iii) The last type of tissue samples consist of abnormal cartilage with loss of height compared to the

adjacent sections of cartilage. The selected tissue samples were cut out with a band saw into wedge-shaped pieces (Figure 1).

Figure 1: The selected area of an osteochondral specimen is being cut into wedge-shape.

Subsequently, the wedge-shaped pieces are arranged in a plastic container submerged under normal saline solution. The specimen pieces are being anchored with rubber bands on to a cutting board submerged under the solution with rubber bands. The orientation of each specimen piece is as follows (Figure 2)

i) cartilage surface facing anteriorly ii) bone surface facing posteriorly iii) widest width is at the base iv) narrowest width is at the apex



Figure 2. The wedge-shaped specimens are being arranged with the cartilage surface (arrow) facing anteriorly and bone surface facing posteriorly submerged under normal saline solution.

MR imaging of the specimens

All examinations were performed on a 1.5 Tesla MR unit (Siemen Magnetic Resonance Imaging System, Magnetom Vision, VB21A, Uhrlagen, German, with the homogeneity of 5ppm over 50cm sphere and field stability <0.1 ppm/h). The whole plastic container with the specimens secured is carefully placed in a knee coil and is imaged in a coronal section using CISS-3D sequence thus obtaining a MR image that has the cartilage surface facing upwards (Figure 3).

Figure 3: CISS 3D MR images in coronal section of the specimens depicting the cartilage surface (arrow) facing upwards.



Due to the configuration of the wedge shaped specimens, as the scan progresses from the base to the apex of the specimens, the width of the specimens on the MR images decreases (Figure 4); thus allowing the exact localization for the thickness measurements by correlating bone width on MR images and corresponding location on the actual specimens measured with electronic calipers. Both the cartilage thickness of the edges (left edge and right edge) at that location on the MR images and on the actual specimens was subsequently measured and compared (Figure 5).

Figure 4: Illustration of how the bone width on the MR images decreases as the specimens are scanned in coronal section from the base to the apex of the specimens. Notice the different layers of the cartilage are visualised well . The low signal area above bone(arrow) is the compact chondrocyte layer and become high signal in earliest sign of degeneration.

TR (ms)

TE Flip Angle (degree)

Matrix (%)

Pixel Size (mm)

FOV (mm)

No. of Slabs

Effective Slice Thickness (mm)

TA

CISS-3D

12.3 5.9 70 60 0.52 x 0.31

160 1 1.5 3 min 25 sec

Table 1: Measurement parameters for CISS-3D used in MR imaging of the specimens.



Figure 5. Illustration showing how the exact localization for measurement thickness is made on the MR images and on the actual specimens. Both the cartilage thickness of the edges (left edge and right edge) at that location on the MR images and on the actual specimens is subsequently measured and compared.

The results were as follows :

The Pearson correlation between the first actual cartilage thickness measurement and the first MRI cartilage thickness measurement by the trainee radiologist was found to be 0.805 which is significant at the 0.01 level (Table 2)

First Actual Cartilage Thickness Measurement

First MRI Cartilage Thickness Measurement by Trainee Radiologist

Pearson Correlation 1 .805 (**)

Sig. (2-tailed) .000 First Actual Cartilage Thickness Measurement

N 114 114

Pearson Correlation .805 (**) 1

Sig. (2-tailed) .000

First MRI Cartilage Thickness Measurement by Trainee Radiologist

N 114 114

** Correlation is significant at the 0.01 level (2-tailed).

Table 2: Pearson correlation between the first actual cartilage thickness measurement and first MRI cartilage thickness measurement by trainee radiologist.



Conclusion of the above study :

CISS 3D was able to detect accurately the loss of cartilage to within 1 mm and also internal changes in the cartilage suggestive of earliest loss of the compact cartilage in deep layer causing a high signal in what should have been a low signal in the deep layer even without loss of thickness of the cartilage. This is now implemented in our standard protocol addressing the problem of detecting these weight bearing defects on standard MRI .

Problem 2 : Translating the correct location of a cartilage defect noted on weight bearing area of Femoral cartilage in a manner that can be understood to the arthroscopist so they understand where to look for the small defects of cartilage . UMMC Thesis.

Solution :

A mapping system was derived from studies at our institution to be able to tell the orthopaedic surgeon where the lesion is following the standard way we do our sagittal scans .

The mapping system is as follows: The mapping system we use is easy as it follows the ICRS system and easily understood by orthopaedic

surgeons. The system is based on the appearance of cartilage from the sagittal sequence of a cartilage specific

sequence like 3D CISS (Siemens) or Balanced FFE (Philips). In this classification, the outermost sagittal image shows the weight bearing area of the femoral condyle, which is limited by the outer border of the anterior and posterior horns of the medial and lateral menisci. The posterior femoral condyle forms the non weight bearing area on this image. These two areas have been designated A2 and A3. A3 is usually correlated arthroscopically by the cartilage beyond 45 degrees of flexion (Figure 6). The sagittal image that first shows cartilage anterior to anterior horn of the menisci reflects the next section. The cartilage anterior to the meniscus is identified as B1 and B2 and B3 (Figure 7) reflects the corresponding areas as A2 and A3, except being more central in the femoral condyle. The next region of interest is the trochlea region of the femoral condyles. In this plane there is no central weight bearing area or posterior region of the cartilage and is identified as C1 (Figure 8). Therefore in this proposed simple classification, the area 1 refers to the cartilage anterior to the meniscus on the MRI in which the knee may normally have up to 5 degrees of flexion. Area 2 refers to the weight bearing areas of the femoral cartilage and area 3 the cartilage posterior to the meniscus which is usually the cartilage noted beyond 45 degrees of flexion on arthroscopy and posterior to the meniscus on the sagittal views. The patella cartilage can be described as being on the medial or lateral facet of the patella or the median ridge. The tibial plateau cartilage can be identified as being on the medial or lateral tibial plateau anterior or posterior region (T1 and T2 respectively). Thus, a lesion of the anterior half of the lateral tibial plateau would be graded as LT1 and a lesion on the posterior half of the medial tibial plateau identified as MT2.

The orthopaedic surgeons used the ICRS mapping system to point out the location of the cartilage lesion (see appendix). Area 1, 2, 3 (as mentioned above) correspond with anterior, central and posterior region respectively, and area A, B, C correspond with medial, central and lateral region respectively of the ICRS system



Figure 6: The outer weight bearing area of the femoral condyle (A2), with no cartilage anterior to the meniscus on extension and cartilage more than 45 degrees on flexion (A3)

Figure 7: There is cartilage anterior to the anterior horn of the meniscus on extension. (B1), the weight bearing area which is normally up to 45degrees on flexion(arrow) , (B2) and that beyond 45 degrees (B3).

A2

A3

B1

B2

B3



Figure 8: Cartilage in the trochlear region (C1)(arrow) with no cartilage noted posterior on flexion.

References :

1. Radiological classification of meniscocapsular tears of the anterolateral portion of the lateral meniscus of the knee. George J, Ramlan AA, Saw KY et al. Australas Radiol. 2000 Feb;44(1):19-22

2. Cartilage T2 Assessment at 3-T MR Imaging: In Vivo Differentiation of Normal Hyaline Cartilage from Reparative Tissue after Two Cartilage Repair Procedures—Initial Experience. Goetz HW, Tallal CM, Stephan EM , et al. April 2008 Radiology, 247, 154-161

3. MRI Imaging of Cartilage and its repair in the knee – a review . Trattnig S, Domayer S, Welch GW et al. Eur Radiol (2009)19: 1582-1594

4. Arthroscopic Measurement of Cartilage Lesions of the Knee Condyle : Principles and Experimental Validation of a New Method. Robert H, Lambotte JC, Flicoteaux R. Cartilage 2011:2(3)237-245.

5. Recent advances in MR of articular cartilage . Gold GE, Chen CA, Koo S , Hargreaves BA, Bangerter NK. AJR Am J Roentgenol 2009 September : 193(3) :628-636

C1



“Duty of Care, Roles and Responsibilities of a practitioner working in the sporting environment”

Hodgson L.

13th Asian Sports Medicine Conference 25-28th September 2013 KL, Malaysia

About the Author

Dr Lisa Hodgson is managing director of Corobeus Sports Consultancy Ltd, UK, a company dedicated to providing NGBs and sporting teams with gold standard sports medicine solutions, focusing on standards, protocols, procedures and training to ensure that sports medicine provision is champion class. Dr Hodgson is also a Lecturer in Sport and Exercise Medicine at the University of Nottingham, for the Masters Degree in SEM and holds a fellowship with the Higher Education Academy; Elite Athlete Screening Consultant for Cardiac Risk in the Young (CRY UK) who focus on screening and research into sudden cardiac arrest/death; Consultant in SEM to the Rugby Football League, UK and their educationalist for immediate care on the field of play. Lisa has recently worked with FMARC (FIFA) on producing a text for first aid provision in Africa. Lisa was the first Head of Sports Medicine for the Rugby Football League in England and as well as working with national and international teams, developed the sports medicine standards throughout the professional game. Lisa has written and developed several courses in immediate care provision in sport and is Course Director of EMMiITS (Emergency Medical Management in Individual and Team Sports), IMMOFP (Immediate Medical Management on the Field of Play for Rugby League), EMFAiS (Emergency Medical First Aid in Sport) and EFAiS (Emergency First Aid in Sport). The former are advanced courses approved by the Faculty of Pre Hospital Care, Royal College of Surgeons Edinburgh. The latter two are intermediate and basic courses respectively for those new to emergency care provision and sports first aid that provide an introduction to working with athletes in the sporting environment, that focus on training, roles and responsibilities, risk assessment and duty of care in this setting. Lisa herself has worked with many sporting teams and recently was Venue Medical Manager for Horse Guards Parade during London 2012 Olympic games and will be holding a similar position with the Commonwealth games in Glasgow 2014.

Abstract

The purpose of this keynote address is to raise the awareness on what working within the sporting environment actually means to health care professionals. It will probably be of most benefit to those aspiring to work within sport and provide information about planning and accepting such a role. The intent is not to discourage one from accepting a role within sport but to ensure one is prepared for anything that may reasonably be expected to encounter so that it can be dealt with appropriately. Ultimately this is the insurance policy for both one’s-self and one’s-athlete and thus the sporting environment.

The sporting environment is a totally different field of medicine to the hospital or clinical setting. Whilst some skills are transferable between settings additional skill sets are also required to ensure that the sporting environment is managed appropriately.

Guidelines, policies and procedures exist within the medical setting of a hospital, practice or clinic but dependent on the sport or governing body of sport that some clinicians will work with, this may not be the case. So the questions transpire – “what is your role?” “what are your responsibilities?” “to whom does your duty of care apply?”

Sports medicine provision to any team adds an advantage to that team and also acts as an insurance policy for that team. Healthy and fit players can compete, those with injuries cannot. Any team that aspires to be anything requires fit and healthy players participating.

Accepting a role within a sporting environment requires one reflecting on several considerations that are not just reliant on having a medical or health care related degree. Some considerations are;

- The duty of care - Roles and responsibilities - Risk assessment



- Medical recording keeping and confidentiality - Medical equipment needs of the sport - Pre hospital emergency care management for competition and training - Education of self and athletes - Medical indemnity and professional insurance

In accepting a sports medicine role within a sporting environment, a significant responsibility ensues. Whether your role is paid or honorary is irrelevant, the same duty of care applies.

A medical qualification or allied health care qualification is not enough, but forms the basis of your suitability to a role within sport. As with any speciality one chooses to work in, further expertise in that area is required. Sport and exercise medicine is no different. One will always be judged against what their peers would do in the same situation, in essence the standard of care must be to a standard that a reasonably prudent professional would provide under similar circumstances [1].

In law, a tort is an injury suffered by an individual as the result of another individual's conduct. The law provides injured individuals the right to be compensated through the recovery of damages. Torts may be intentional or unintentional, negligence is an unintentional tort. Negligence law was founded on the belief that those harmed as the consequence of others' carelessness or failure to carry out responsibilities properly were entitled to be compensated. It is based on four legal elements first that there is a duty of care, second that that duty is breached, third that the breach caused harm and lastly actual harm occurred [2].

Medical negligence cases already exist, in the UK they are based on the Bolam test. The majority of peers who come under scrutiny do so because they did not have the required skills to carry out the duty of care that they accepted [3-6].

A recent suit was established in the USA (August 2013) against the coaching staff, athletic trainer, NCAA and helmet manufacturers for the death of a 22 year fullback who died in contact training. Repetitive trauma over several days existed resulting in a final collision on the third day resulting in an acute subdural haematoma and massive vascular engorgement. (7,8). The family claim it is inconceivable with all the attention on concussion management that no unified enforcement existed to prevent the dangerous practice or to ensure proper medical attention. The death is felt to have been preventable and forms the basis of their claims of negligence against all the parties named [7]. Largely, established medical malpractice govern claims by athletes for injury or death caused by improper treatment by health care providers [9]. Providing treatment of injuries and medical clearance for sports participation involves legal as well as medical issues. The threat of lawsuits exists for the sports medicine professional whether the athlete is allowed to play or not. Allied health care professionals and team physicians have been sued for prematurely clearing athletes, and also been sued for not permitting athletes to play [10-13].

One’s duty of care is foremost to their athletes irrespective of the management system within the sport and who is the line manager or salary provider. Essentially the medical team responsible for the athletes cannot also be responsible for the crowd, another team should exist for the sole purposes of crowd care. That is not to say, in an emergency one would not have an ethical and moral ‘vicarious’ duty to act to assist with crowd care having firstly dispensed with one’s own duty of care, in essence stopping sport before assisting so that no further harm could ensue to an athlete.

Handing over one’s duty of care should also be carefully considered. This is only complete if handed over to an established health care professional and ensuring relevant information regarding the mechanism, assessment and treatment is relayed. This is not discharged if the athlete is handed over to a first aider (non qualified person) for transport or if pertinent information is excluded. As part of the role one must ensure they meet, greet and establish relationships with those that may assist in onward referral or hospital transfer to ensure the transfer of the duty of care. A suit in the USA resulted in the court awarding $1.5 million dollars in damages, including $450,000 from the athletic trainer for neglecting to hand over relevant information that would have assisted with onward care [14].

National governing bodies of sport and the sporting team/event also have a duty of care and generally one of these is the provision of medical support, the role one is accepting. It is imperative that one is aware of what role and what responsibilities are being accepted. Essentially one should establish a job description and contract with these specifically detailed, this may prevent litigious situations from occurring (15).

A risk assessment of the sport, venue and potential injuries is essential. Establishing action plans for all case scenarios as well as risk reduction procedures is paramount in establishing your duty of care. One of the risk assessments is self-reflection. Does one have the skills required to work in this sport? Does one have the up-to-date knowledge and experience to accept the role being offered? Does one have access to the emergency equipment that may be required to prevent a life threatening injury? Whilst risk management procedures will not help sports medicine professionals defend themselves in a lawsuit they should help prevent litigious situations from occurring. A physician and health care professional has a duty to conform to good and accepted standards of medical care in determining whether an athlete continues to participate. In Classen v Izguierdo, a ringside physician refused to stop a boxing match in which a participant received several blows to the head. The boxer



died from the multiple head injuries sustained, and the court indicated in the opinion that the failure of the physician to keep the athlete from competing may have constituted malpractice [16]. In the case of an athlete with a head injury, there is uncertain potential for permanent disability or death. Given the extreme risks, it seems reasonable to err on the side of caution [17].

Medical standards should be up to date and updated periodically as sport and exercise medicine practice evolves for athlete safety. Adherence to outdated sports medicine guidelines is not a recognized defense. It is imperative that has a health care professional that skills and knowledge relevant to the sport are maintained. An example is if the sport has a propensity to concussions then the established management principles outlined in Zurich 2 [18] should be followed. If a risk of cervical spine injury and extrication exist then the clinicians should be up to date in emergency care. In the UK, there has been training in pre-hospital immediate care for pitch side physicians and therapists for the past decade [19]. A knowledge of basic first aid is not enough to work in a sporting environment, an established sports course that focuses on emergency care is an essential pre-requisite to accepting a role in sport [15]. Many courses exist but choose wisely and ensure the course meets the demands and is run by experienced instructors. Example courses can be viewed at www.corobeussportsconsultancy.co.uk.

Thankfully the incidence of catastrophic and severe injuries in the athletic population is low, however when these events do occur pitch-side, the SEM practitioner present will be expected to deal with this quickly and appropriately and may have very little emergency experience. Sudden cardiac arrests and deaths in sport have made media headlines recently [20-22] and whilst infrequent do occur. Whilst risk assessment can look into preventative measures such as cardiac screening in this scenario, not all can be prevented and effective management in a life-threatening scenario will be required with timely access to essential equipment. One must be prepared for this and have all required equipment to hand [23]. The same applies to the common injuries. The supply of this equipment is subject to debate and should be provided to you by the sport but it is the responsibility of the medical staff to check the equipment is present and in working order before any sporting event begins. The level of sport and affluence of the sport will decide what equipment is essential and what is only desired, but as part of one’s risk assessment one must decide what one can and cannot do without to ensure the safety of their athletes. Education of self and others in the use of the equipment is also essential.

Finally medical record keeping and documenting injuries as well as medical examinations and pre participation screening is an essential role and must be kept and stored in a secure location. Patient confidentiality is paramount and sharing of information cannot be done without the express consent of the athlete.

References

1. Osborne, B. Principles of liability for athletic trainers: Managing sport related concussion. J Athl Train 2001;36(3):316-321.

2. Dobbs DB. Torts and Compensation. St. Paul, MN: West Publishing Co; 1993. 3. Bolam vs Frien Hospital Mangagement Committee (1957) 1 WLR 583 4. Watson vs Bristish Boxing Board of Control (2001) QB 1134 5. Bolitho vs City Hackney Health Authority (1997) 4 All ER 771 6. Brady vs Sunderland AFC and Boobis & England (1998) CA (unrep) 7. Derek Sheely et al v NCAA et al http://nflconcussionlitigation.com/ 8.http://www.washingtontimes.com/news/2013/aug/22/death-frostburg-state-player-dereksheely-due-egre/ 9.Mitten MJ. Team physicians and competitive athletes: allocating legal responsibility for athletic injuries. U Pitt

Law Rev. 1993;55:129. 10. Kampmeier v Nyquist. 553 F.2d 296 (2d Circ. 1977) 11. Grube v Bethlehem Area School District. 550 F. Supp. 418 (E.D. Pa. 1982) 12. Wright v Columbia University. 520 F. Supp. 789 (E.D. Pa. 1981) 13. Poole v South Plainfield Board of Education. 490 F. supp. 948 (D.N.J. 1980) 14. Pinson v State. 1995 Tenn. App. LEXIS 807 15. Hodgson, L. Working in sport and exercise medicine – Be Prepared part 1 SportEx med 2010;46;17-22. 16. Classen v Izquierdo. 137 Misc. 2d 489 (1987) 17. Knapp v Northwestern University. 101 F. 3d 483 (1996 U.S. App.) 18. McCrory, P. Meeuwisse, W,H. Aubry M et al Consensus statement on concussion in sport: the 4th

International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258

19. Hanson J. Sports pre-hospital immediate care courses in the United Kingdom – attempting to “treat” sudden cardiac death. Scottish Medical Journal 2010;55(2):35

20. Fabrice Muamba suddently collapses FA Cup Semi Final, YouTube 19 March 2012 http://spxj.nl/L20iAb



21. MacAree, G. Poermario Morosini dies following heart attach on pitch, SBNATION on YouTube 31 May 2012 http://spxj.nl/L7Ayzu

22. Olympic swimmer dies: Norwegian hopeful Alexander Dale Oen suffers cardiac arrest, The Mirror 1 May 2012 http://spxj.nl/KxsHvW

23. Hodgson, L. Sudden Cardiac Death in Sport – Be Prepared! Part 3. SportEx Med 2012;53:20-25.



Promotion of health related physical fitness of people with intellectual disabilities

Inal H.S.

Yeditepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Istanbul, Turkiye

Children with intellectual disabilities may usually have delay in their motor functions besides their intellectual, social, communicational or academic activities (Melville & et.al. 2005). For instance, they present some inadequacy in their balance, speed, endurance, strength, flexibility, agility, reaction time and posture when compared with their pears (Winnick & Short, 1999). Cantell & McGhee (2006) states that the insufficiency of cognitive perception and attention of the children with intellectual disabilities may exhibit decreased perceptual-motor skills, spatial awareness, body image, kinesthetic sense, balance and posture. Thus, the interaction of these features may detoriate their health related physical fitness and decrease their integration to physical, recreative and sportive, as well as social activities.

A study we have done on thirty (30) children at educable intellectual level studying in a primary and vocational school who were between the ages of 7-15 years showed that they had mild to moderate postural changes as pesplanovalgus, round shoulder, forward protruded head, depressed chest, knee deformities, lordosis, kyphopsis, lordosis and abdominal bulging. Deformities of knee joints (varus-valgus, P < 0.01 and recurvatum, P < 0.05) were also found negatively related with the duration of stair climbing and walking, respectively. Additionally, there was a negatively significant relationship between the handgrip strength and the duration for crouching and standing up (P < 0.05). Thus we concluded that, postural changes and hand grip strength of the children with intellectual disabilities may effect their balance, and their speed of walking and stair climbing (Inal et al. 2008) that are important activities may effect their everyday life.

Physical activity and sports are considered as effective means to improve posture and increase the physical capacities, especially the strength, speed and endurance, overall the neuromuscular co-ordination of the children with intellectual disabilities (Lewis & Pinkham; Pinkham, 2005). As an inherited feature, reaction time that is a determinant factor of speed (Bompa, 1990) may also be improved. A study aiming to search the reaction time of the youngsters with mild to moderate intellectual disabilities actively involving with table tennis (n = 14; 17.21±1.11 yrs) and the sedentary (n = 13; 15.46±0.08yrs) whom are only joining physical education classes in their schools, have showed that the children involving with sports (514.44 ± 1.04msec) were having shorter duration of reaction time then the sedentary (642.27 ± 2.54msec) (P < 0.05) (Koldas & Inal, 2004). Thus, the physical activity and the sports training programs assigned according to the achieved results of the assessment interventions on the health related physical fitness of children with intellectual disabilities can promote their performance.

On the other hand, the physical inadequacies of the children especially with severe intellectual disabilities may drag them into a more motionless and sedentary life; consequently some chronic illnesses such as musculoskeletal, cardiac and respiratory diseases, obesity and diabetes mellitus could be arisen that decrease their quality of life and threaten the life (Hahn & Cella, 2003; Moran et al., 2005). Obesity is a serious life threatening problem of the people with intellectual disabilities. They are 30-50 % more obese when compared to general population (Moran et al., 2005). Melville et al. (2005) have reported increased incidence of obesity among female with Down’s syndrome. The BMI of the youngsters with intellectual disabilities was reported as for tennis players 27.45 ± 2.65 kg/m² and for sedentary 33.81 ± 0.0 kg/m² that were both overweight and obese level, respectfully (Koldas & Inal, 2004) according to their age and gender (Cole et al., 2000). In relation to these data, since they are more liable to gain weight, regular physical activity and sports as effective tools to control weight and of course to decrease the risks of cardiovascular problems (Lewis & Pinkham, 2005) should be disseminated among the people with intellectual disabilitis as a positive health behavior.

Overall, for promotion of the physical capacity of the people with intellectual disabilities and for assessing the achieved improvements after certain physical activity or sports training programs, which may be for recreative or competitive purposes, they need to be evaluated regarding to their health related physical fitness.

The valid and reliable tests in disability sports give us the opportunity to utilize the standard norm tables (Short, 2005; Skowroński et al., 2009) in addition to the facilitation of the comparative studies in the area of disability sports. Among the tests available in literature, Test of Gross Motor Development-TGMD II, is specific for the Basic Movements period, is developed particularly to evaluate the gross motor development of pre-



school and elementary school children that are between age 3 and 10 with/without intellectual disabilities (Ulrich; Palisano, 2000; Simons et al. 2007). The Brockport Physical Fitness Test is another common and practical test, which was developed by New York State University. It is for children and adolescents between age 10 and 17 who are healthy and having disabilities (Pinkham et al., 2005). However it is possible to comprise a special test battery particular to an individual, or a specific disability, or an age group by choosing from among the 27 tests it contains. The other common test named as Eurofit Test Battery is developed in Europe, as a method that can be used for individuals of all age groups and levels of physical activities (Eurofit, 1988). As Skowroński et al. (2009) have stated, some modifications in Eurofit Test Battery proposed for children disabilities and some practices have been simplified and made more efficient especially for the individuals with intellectual disabilities under the name of Eurofit Special.

The collected data may provide information about the health related physical fitness level of the children interested with adapted sports. They also furnish the professionals as well as the families about the developmental process of the children from their fundamental movement phase towards the specialized motor skills within the limits of their physical and intellectual capacities. Additionally, they supply detailed information to the couches or the physical education teachers whom may do counseling the individuals and the families to practice sports most suitable for their physical condition and skills (Munson et al., 2004).

References

1-Bompa OT (1990). Theory and Methodology of Training. The key to athletic performance. Second Edition. Kendal/Hunt Pub.Iowa.

2- Cantell M & McGehee D. (2006). Movement quality in children with developmental delay: Midline and weight sensing as markers of adaptive movement. Body, Movement and Dance in Psychotherapy, 1, 129–41.

3- Cole TJ, Bellizzi MC, Flegal KM & Dietz WH. (2000). Establishing a standard definition or child overweight and obesity worldwide: international survey. British Medical Journal 6;320 (7244):1240-3

4- Eurofit (1988). Report of the European Conference Special Olympics 1988-1990. The Road to Europeanian Headquarters (pp.78-79).

5- Pinkham F, Haley SM, Rabin J & Kharasch VS. (2005). A Fitness Program for children with disabilities. Physical therapy, 85,1185-1200.

6- Koldas H & Inal S. (2004). Effects of sports on the reaction time of the children with Down’s Syndrome. 7th International Congress of Sports Medicine Association of Drama, Greece. 29April-2 May 2004,

7- Hahn EA & Cella D.(2003). Health outcomes assessment in vulnerable populations: Measurement Challenges and Recommendations. Archives Physical Rehabilitation and Medicine, 84 , Supp l2, 35- 42.

8- Inal S, Kaya B, Kırandı Ö, Orhun B, Güngördü O, Keser A & Donuk B. (2008). Health Promotion of Children with Mental Challenges Via Sports and Physical Activity. The 50th ICHPER-SD Anniversary World Congress, May, 9-12, Kanoya, Kagoshima, Japan.

9- Lewis CL & Pinkham F. (2005). Effects of aerobic conditioning and strength training on a child with Down syndrome: a case study. Pediatr Phys Ther. Spring;17:30-6.

10- Melville CA, Cooper SA, McGrother CW, Torp CF & Collacott R. (2005). Obesity in adults with Down syndrome: a case-control study. J Intellect Disabil Res. Feb;49(Pt 2):125-33.

11- Moran R, Drane W, McDermott S, Dasari S, Joy B, Scurry JB & Platt T. (2005). Obesity among people with and without mental retardation across adulthood. Obesity Research 13:342-349.

12- Munson D, Corbin SB & Pastorfield C. (2004). Fitness survey: survey of Special Olympics coaches regarding athlete fitness. Special Olympics, health athletes, health promotion. (www. Specialolympics.org/healty_athletes.aspx)

13- Simons J, Daly D, Theodorou F, Caron, C, Simons J & Andoniadou E. (2007). Validity and reliability of the TGMD-2 in 710-year-old Flemish children with intellectual disability. Adapted Physical Activity Quarterly, 25:71-82.

14- Short FX. (2005). Measurement and assessment. (In) Adapted physical education and sport. Joseph P. Winnick Editor, p.55-76 Human Kinetics, Illinois.

15- Skowroński W, Horvat M, Nocera J, Roswal G & Croce R. (2009). Eurofit Special: European Fitness battery score variation among individuals with intellectual disabilities. Adapted Physical Activity Quarterly, 26:54-67.

16- Ulrich DA. (2000) Test of Gross Motor Development. Austin, TX: Pro-ed. Publishers. 17- Palisano RJ, Hanna SE, Rosenbaum PL, Russel DJ, Walter SD, Wood EP, Rania PS & Galuppi BE.

(2000). Validation of a model of gross motor function for children with Cerebral palsy. Physical Therapy, 80: 974-985.

18- Winnick JP & Short FX. (1999). The Brockport physical fitness training guide. Human Kinetics, Illinois.



Integrating physical, mental, emotional and energy components into athletes’ lifestyle to ensure athletic excellence and health

Lal P.R.*, Balakrishnan B.**

*Lady Irwin College, Delhi University, New Delhi, 110001 India. Email: [email protected]. **Isha Institute of Inner research, Isha Foundation, Velliangiri Foothills, Coimbatore, India.

Abstract

This review paper reconnoitres the integration of the physical, mental, emotional and energy components into athletes’ lifestyle to bring about the necessary change in their consumption behaviour- with specific reference to fluid intake behaviour. It explores the effects of subtle levels of dehydration in athletes on their psycho-physiological changes and reasons for this dehydration with an aim to develop and offer effective tools that enable athletes bring about the necessary changes in fluid consumption behaviour. It also highlights the differences in hydration status, psycho-physiology and other related parameters post implementation of these tools reporting a series of studies in this direction.

Key words: hydration, psychophysiology, behaviour change communication.

Introduction

The quest for excellence in sport predisposes an athlete to undertake excessive training loads for higher levels of achievement. This load consistently improves performance, but also generates sport related stress, predisposing an athlete to various threats for which adequate scientific support is planned, implemented and is in a state of continuous evaluation and improvement, one important area being the hydration status of athletes. While the initial interest in this area emerged as the effect of prolonged exercise on progressive water and electrolyte losses(1,2,3) and dehydration related deterioration in physiological function & exercise performance(4), recent studies have highlighted the effect of dehydration on the long term health consequences such as increased DNA damage after high intensity exercise(75% VO2 max)due to reactive oxygen species-induced DNA damage associated with lymphocytopenia (5,6). The level of dehydration leading to ill effects(7,8)in varied environments(9), reasons for this ‘voluntary dehydration’ during physical activity(10-14),importance of rapid and complete rehydration(15), strategies for preventing body water deficit with improved fluid consumption to attenuate the reductions in blood volume, cardiac output, muscle& skin blood flow and rise in core temperature to reduce fluid loss, lower exercise heart rate, improve recovery time and reduce heat exhaustion( 16), benefits of natural drinks(17-18) and factors leading to adequate hydration status and their overall benefit have been studied extensively(19-20). Expert recommendations(21,22,23), Position Statements and hydration protocols (24 – 25) are also in place to aid improved hydration. However, the combined effect of exercising in the heat along with poor hydration practices on the psycho-physiological profile(PPP) is a relatively unexplored area as is the persistent question on ‘how’ to bring about this essential change in hydration in practice. Human performance is an interplay of physical, mental, emotional and energy parameters, with one parameter having an effect on the other for its capacity to perform and maintain health conditions. The brain – body relationship and how this inter-related performance is affected by the fluid inputs to the body, will further highlight the extent to which prevention and recovery methods need to be implemented in sports. Also, many athletes, especially those who form the feeding cadre to the elite group in the 3rd world countries often train in uncontrolled environment conditions and attend to daily occupations or day long academic classes, thereafter. Hence, this series of studies was undertaken with the aim of exploring the psycho-physiological and hydration profiles of athletes training towards sport-excellence, their awareness and other challenges regarding fluid intake, strategies that bring in a positive change in fluid intake behaviour and effective methods to ensure this learning process or establish these improved practices. The studies also aimed at developing and offering effective tools that enable athletes bring about the necessary changes in fluid consumption behaviour. The differences in hydration status, psycho-physiology and other related parameters post implementation of these tools are also highlighted.



Methods:

A series of studies were conducted to explore this area. Most studies followed the non- randomised, case control design. A broad-base of volunteers interested to participate in the study, were screened for inclusion within a set criteria, designed for each study. All individuals meeting the criteria were selected and were then divided into two groups to formulate the experimental and the control group. Where only interventions were different, this division was randomised. However, when influence of their current environment had to be explored, for example, effect of exercising in low temperature & humidity conditions, the division was non-randomised, based on the capacity of the subject to present themselves at the respective exercise arena. To elicit information, questionnaire, psycho-physiological measurements, biochemical assessment, anthropometric measurements and dietary surveys were used and SPSS version 17 was used for analysis of the data collected with these tools.

Results:

Results of the studies are presented under various heads covering all topics included.

Hydration status and psychophysiology:

In a case control study(26) on a convenience sample of 60 collegiate, basketball women(18-22 years), 30 training in open-air at temperatures 31-37oC and 30 matched counterparts training in environmentally controlled centres, selected via purposive sampling, the effect of body hydration status on their psycho-physiological profile(PPP) was studied. The pre and post exercise values of PPP(heart rate, simple reaction time, choice reaction time and electro-dermal response) was measured; simultaneous measurements of body hydration status(urine specific gravity and urine pH) and perceived exertion during exercise were made using heart rate monitor, reaction timer and electrodermal monitors from Medicaid, India; multistix strips and Borg’s Scale respectively.

At start of the study, screening ensured similarity in the subjects’ age, body mass index, total body water, physical activity level, total daily energy expenditure and nutrient intake. A stringent selection criteris ensured that the two groups - the college basket ball team (BBG) and the college athletes training in a fitness centre(CG) were similar in all aspects except that the CG was training in controlled, comfortable (20-24oC and relative humidity of <50%) environment.

Results of the study indicated that there was no significant difference in pre-exercise body hydration status and psycho-physiological parameters between both groups. Table 1,2 and 3 describe the pre-exercise and post- exercise body hydration and psychophysiological status of the two groups.

Table 1: The Pre and Post exercise Body Hydration (USG and UpH) of collegiate athletes

USG UpH

BBG CG BBG CG

Mean ± SD Mean ± SD Mean ± SD Mean ± SD

Pre- exercise 1.022 ± .008@ 1.019 ± .008@ 6.18 ± .405@ 6.04 ± .367@

Post- exercise 1.029 ± .005$ 1.025 ± .007$ 5.99 ± .445& 5.76 ± .401&

t value (Paired t-test)

7.61** 6.46** 3.86 ** 6.46**

** Significant at .01 level; @ Not significant;$ t= 2.59, Significant at 0.01 level; & t = 2.10, significant at 0.05 level



Table 2: The pre exercise psycho-physiological status of BBG and CG

Parameter Group Pre (Mean ± SD) t-value

HR BBG 73.13±5.00

CG 70.83±4.84

1.93NS

RTS BBG 0.181±0.02

CG 0.180±0.02

0.15 NS

RTC BBG 0.240±0.03

CG 0.239±0.03

0.19 NS

GSR BBG 457.43±122.57

CG 440.40±110.81

0.56 NS

NS- Not significant

On comparing the post exercise psycho-physiological status (HR, RTS, RTC and GSR) of BBG with the post exercise psycho-physiological status (HR, RTS, RTC and GSR) of CG, significant differences were seen in HR (p<0.05). This indicated that changes in the psycho-physiological status occurred from the pre exercise to the post exercise period in both BBG as well as CG the magnitude of change,

Table 3: Comparison of post- exercise psycho-physiological status between BBG and CG

Parameter Group Post (Mean ± SD) t-value

HR BBG 86.90±8.19 2.59*

CG 81.33±8.43

RTS BBG 0.219±0.03 1.51NS

CG 0.206±0.03

RTC BBG 0.316±0.03 0.87 NS

CG 0.286±0.03

GSR BBG 359.27±121.97 0.23 NS

CG 352.07±123.59

* Significant at 0.05 level; NS not significant

being significantly higher in BBG as compared with CG who exercised in a comfortable controlled environment (Table 3). Rated perceived exertion: The 9-point Borg’s scale was used to rate perceived exertion in the study and the results are presented in figure 1.



Figure 1: Rated perceived exertion of CG and BBG

02468

101214161820

no ex

ertio

n at

all

exter

mely lig

ht

very

light

light

somew

hat h

ard

hard

(hea

vy)

very

hard

extre

mely ha

rd

maxim

al exe

rtion

Num

ber

of re

spon

dan

ts

BBG CG

The ratings for perceived exertion ranged from ‘no exertion at all’ to ‘extremely hard’ throughout the 90 minutes session for BBG, whereas they ranged from ‘no exertion at all’ to ‘hard’ in CG, indicating that CG was not as fatigued as BBG. No subject from either group reported maximal exertion during the exercise session. This data indicated that the collegiate basketball group perceived the same quantum and intensity of exercise as harder than their counterparts who were exercising in controlled comfortable environments.

Knowledge, attitude and practices regarding hydration

Data on the subjects’ knowledge, attitudes and practices(KAP) related to hydration, was collected in detailed questionnaires.

Results of this data showed low awareness and faulty practices in both groups (26b) with respect to all knowledge aspects such as weight and urine monitoring, quantum of fluids needed, type, concentration and temperature of fluids that are beneficial.

Similar results were observed in another study by Jessri et al, 2010 on 66 basketball players and 141 football players from 4 medical and 8 non-medical universities in Tehran to assess the nutrition knowledge and the factors determining knowledge and concluded that there is a need to enhance knowledge related to hydration among athletes.

Both groups had a positive attitude and the awareness that hydration was important for exercise performance, although all subjects had a low score in their hydration practices. Hence, the poor body hydration status of the athletes could be attributed to the lack of awareness regarding important aspects of hydration in sports, due to which they were unable to make wise choices to strengthen their hydration practices.

In this formative study, post exercise, the loss in body mass averaged 0.19% - 0.4% in the two groups, indicating a subtle level of dehydration of <1% in both groups. The body hydration indicators and PPP deteriorated significantly(p<0.01) in both groups when compared with their pre-exercise levels, indicating post-exercise deterioration. EG showed significantly higher values of urine specific gravity(p<0.01), urine pH(p<0.05) and heart rate(p<0.05), when compared with CG, post exercise and a positive covariance between urine specific gravity and heart rate, implying that levels of dehydration and deterioration in psycho-physiological response may co-vary or be related. This study concluded that even subtle dehydration of 0.4%, in hot environment, amounting to small water loss of 190-220ml particularly due to poor hydration knowledge and practices, may induce decrements in the PPP (HR). This was later supported in another study (27) at 0.7% dehydration, which also observed a deterioration in choice reaction time along with heart-rate and perceived exertion, post exercise. Hence, such subjects may be at a potential risk of lower sports or occupation performance and an increased risk of injuries (our later study(27c) did not find significant links with injury status) and impaired long term health status due to psycho-physiological deterioration caused by the stress of



training, especially in hot, humid conditions. The formative Research study(26b) also developed an awareness tool based on the database generated for improving the practices of these athletes.

Effect of the awareness tool and a hydration strategy on the hydration status and psychophysiology of collegiate athletes

The hydration awareness tool prepared after the formative study(26) reported earlier in this paper, was utilised in another study(27b) on collegiate basketball players, aimed at enhancing hydration knowledge and practices of athletes training in uncontrolled environments, attaining a rehydrated status after removing barriers to improved hydration status through a fluid replacement strategy using three popular fluids and studying its effect on the subjects’ PPP. Forty college going women basketball players, selected via criteria based purposive sampling, were randomly divided into CG and EG. Hydration KAP (via questionnaire), PPP (HR & CRT); body hydration status (USG & UpH) and perceived exertion was studied. The awareness tool was utilized for improving the hydration knowledge and practices of CG and EG, after which, an implementation strategy for fluid replacement (WOP) was developed and implemented in the EG only. The effect of hydration with three fluids- Water, Lemon water and Glucon-D on the PPP was also assessed. All subjects’ baseline data and data after implementation of the tool was collected and data after the implementation of the hydration strategy was taken in the EG alone.

At Baseline: T- test between the baseline data of the two groups revealed that there was no significant difference in the knowledge related to hydration between both the groups i.e. both the groups began the study with similar hydration knowledge (t= 0.64, NS). This observation supports the earlier studies in concluding that there is a need to enhance knowledge related to hydration

After implementation of the awareness tool: To compare the changes in knowledge related to hydration in each group before and after the implementation of the tool, the paired sample t-test was used. There was a highly significant difference obtained in both the groups indicating that the awareness tool can bring in a significant improvement in the knowledge regarding hydration (Table4).

Table 4: Hydration knowledge at the baseline and after the tool implementation

CG EG

Baseline 10.55 ± 3.81 9.65 ± 4.95

After tool implementation 23.55 ± 5.57 26.75 ± 7.26

T value 9.97* 15.09*

*Significant at 0.01 level

When scores of both groups were compared, using t- test, it revealed no significant difference in the knowledge related to hydration between both the groups after the administration of the tool, which indicates that both groups equally improved in their knowledge after the implementation of the tool (t= 1.56, NS). However, data indicated that there was further scope for improvement to attain closer to centum scores in the areas of weight monitoring, quantity, timings and pattern of fluid consumption that may further enable practicing adequate hydration behavior.

After implementation of the WOP strategy in the experimental group: After the experimental group underwent the WOP strategy, T test between the groups revealed that there was a highly significant improvement (p<0.01) in the knowledge scores of the EG indicating the importance of experiential learning in further increasing the knowledge and awareness regarding hydration. Therefore the need for implementing a hydration protocol for athletes as suggested by our formative study, (Kataria et al, 2010) proved to be effective (Table 5).

Table 5: Hydration knowledge after the implementation of WOP strategy

Groups EG

After tool administration 26.75 ± 7.26

After WOP strategy 46.55 ± 0.94 t value 12.08*




Repeated measure ANOVA was applied in the EG to assess hydration knowledge between the baseline, after tool implementation and after WOP strategy (Table 6).ANOVA showed that there was a significant difference in the knowledge of the subjects before and after implementation of the self awareness tool which improved significantly with further implementation of WOP strategy.

Table 6: Changes in hydration knowledge of EG after the tool and WOP strategy

Groups Mean difference Baseline and after tool administration -17.10* Baseline and after WOP strategy - 36.90* After tool and after WOP strategy 19.80*

*significant at 0.01 level

Data on knowledge scores indicated that at start of the study, all subjects in both groups had scores below 40%. This improved after the implementation of the tool with 13 subjects scoring above 65% in the CG and 15 subjects above 75% in the EG. The scores further improved to 20 subjects scoring 100% after the fluid replacement strategy in the EG (Table 7).

Table 7: Improvement in hydration knowledge

Percentage NO. OF SUBJECT NO. OF SUBJECTS NO. OF SUBJECTS

Baseline After tool implementation After WOP strategy

CG EG CG EG EG

0-20% 12 12 0 0 0

20-40% 9 8 7 5 0

40-60% 0 0 10 8 0

60-80% 0 0 3 6 1

80-100% 0 0 0 1 19 These results indicate the benefit of combining awareness tools with experiential learning in achieving improved knowledge. Hydration practices at baseline and after tool implementation: Paired sample t-test was used to compare the changes in hydration practices after implementing the tool. There was a highly significant difference obtained in both the groups indicating that there is an improvement in the reported practices after the administration of the self-awareness tool (Table 8). Thus, the tool was effective in significantly improving the reported practices related to hydration.

Table 8: Hydration practices(reported) at the baseline and after the tool implementation

CG (n= 20) EG (n= 20)

Baseline 1.65 ± 1.78 2.60 ± 5.50

After tool implementation 8.55 ± 5.19 9.65 ± 3.51

t value 7.47* 8.54*




Hydration practices after the WOP strategy

T test between the groups revealed that there was a highly significant difference (p<0.01) in the reported practices of the EG after the implementation of the WOP strategy which re-emphasizes the need for experiential learning in improving the practices regarding hydration (Table 9).

Table 9: Hydration practices after the implementation of WOP strategy

Groups EG After tool administration 9.65 ± 3.51 After WOP strategy 16.75 ± 1.16 t value 8.04*


Repeated measure ANOVA was applied in the EG to assess hydration practices between the baseline, after tool implementation and after WOP strategy. Mauchly’s test indicated that the assumption of sphercity is not violated (sig= 0.167).ANOVA showed that there was a significant difference in the practices of the subjects before and after implementation of the self awareness tool and after the implementation of WOP strategy (Table 10).

Table 10: Changes in hydration practices of EG after the tool and WOP strategy

Groups Mean difference (I-J) Baseline and after tool administration - 7.05* Baseline and after WOP strategy -14.15* After tool and after WOP strategy - 7.10*


This data indicates that WOP strategy is more effective than the awareness tool for improving the knowledge and awareness as well as reported practices regarding hydration.

Body hydration and PPP:

The pre-exercise body hydration status and PPP(Table 11) of CG and EG were similar. The post exercise hydration and PPP showed significant changes (p<0.01) in both the groups, indicating exercise induced deterioration.

Table 11: Psycho-physiological profile of EG and CG at the baseline level

Parameter Group Pre Post t-value

Mean ± SD Mean ± SD

HR EG 71.65 ± 8.27 84.65 ± 6.39 14.58*

CG 70.20 ± 7.08 79.4 ± 8.05 7.79*

CRT EG 0.322 ± 0.07 0.49 ± 0.13 7.90*

CG 0.31 ±0.02 0.338 ± 0.01 6.69*


In case of fluid trials of EG, pre-exercise hydration status was not significantly different when compared with baseline data, indicating inconsistency in following the practices and reporting dehydrated for training, when not under supervision.



Table 12: Comparison of mean Pre and Post exercise Heart rate of EG for fluid trials

Trials Pre-exercise HR Post- exercise HR t-value


Baseline 71.65 ± 8.27 84.65 ± 6.39 14.58*

Water trial 70.92 ± 8.05 79.62 ± 7.30 -8.72*

Lemonade Trial 73.07 ± 7.95 77.71 ± 6.59 -5.93*

Glucon – D trial 72.35 ± 7.33 75.06 ± 7.55 -6.47*

*Significant at 0.01

Repeated Measure ANOVA revealed that Glucon- D significantly improved HR (Table 12, Mean difference=9.59, p<0.05), Water improved RT (Table 13, Mean difference= 0.112, p<0.05) and Lemon water improved USG (Mean difference= 0.008, p<0.05), as compared to the baseline value, indicating that rehydration with any fluid was beneficial for improving hydration status and different fluids may affect different PP parameters.

Table 13: Comparison of mean Pre and Post exercise Reaction time of EG for fluid trials

Trials Pre Post t-value


Baseline 0.322 ± 0.07 0.49 ± 0.13 7.90*

Water trial 0.329 ± 0.09 0.357 ± 0.09 -2.73**

Lemonade Trial 0.338 ± 0.082 0.342 ± 0.086 -1.03***

Glucon – D trial 0.345 ± 0.10 0.362 ± 0.13 -1.58 ***

*Significant at 0.01; ** Significant at 0.05; *** Non significant

The body hydration status as reflected by urine specific gravity and urinary pH reflected that all subjects started exercise at similar, low levels of hydration. Fluid trials in the experimental group(Table 14, 15) were conducted to assess changes in the hydration status

Table 14: Hydration status (USG) of the EG for all fluid trials

Trials Pre Post t-value Mean ± SD Mean ± SD Baseline (n=20) 1.016 ± 0.009 1.023 ± 0.006 4.13*

Water trial (n=13) 1.013± 0.01 1.015 ± 0.008 -0.93**

Lemonade Trial (n=14) 1.016± 0.010 1.013 ±0.007 1.60**

Glucon – D trial (n=17) 1.016± 0.009 1.010 ±0.006 3.80*

*Significant at 0.01; ** Non-significant

ANOVA was applied between pre exercise measurements for differences among the trials. The test revealed that at start of all the trials there was no significant differences in USG (F= 0.34, NS) and UpH (F= 1.42, NS). Further analysis into the status revealed that the definite number of subjects increased in all the categories from n=13 (water trial) to n= 14 (lemonade trial) and n=17 (Glucon-D trial).This shows that strategy was only marginally effective in bringing a change in the number of subjects who consumed fluid at home when not under supervision although this was not statistically significant



Table 15: Hydration status(pH) of EG for all fluid trials

Trials Pre Post t-value Mean ± SD Mean ± SD Baseline (n=20) 5.88±0.39 5.65±0.48 2.5*

Water trial (n=13) 6 ±0.00 5.85±0.37 1.47**

Lemonade Trial (n=14) 6 ±0.00 5.86 ± 0.36 1.42**

Glucon- D trial (n=17) 6 ±0.00 5.88±0.33 1.46**

*Significant at 0.05 ** Non-significant

This study highlighted the benefit of rehydration in improving PPP during exercise and the importance of WOP strategy for achieving adequate hydration status. Although the WOP strategy proved more effective than the awareness tool for improving knowledge, awareness and reported practices, there clearly emerged a scope for further intervention to achieve the necessary practices. Recognising the dietician’s responsibility as that of bringing about the necessary change in diet behaviour, the recognisable challenge of connecting athletes’ knowledge with action and behaviour change, persisted.

Preparing a BCC based on the holistic module

Our subsequent studies(28,34,35) recognised that nutritional behaviour is framed by a multilayer process including biological, anthropological, economic, psychological, socio-cultural, and home economics related determinants and it is shaped by the individual situation (29) and is complex, making behaviour change also complex. We attempted including all components of behaviour change, that have the ability to assist in bringing about a conscious change in practices. Many commonly-used theories on behaviour change provide best information on changes and motivation(30) that are needed to promote healthy behaviour and why, but not on how changes can be induced.

Thus, the need for a tool for conscious change in the biological process, strengthening the psycho-physiology/cognition and motivation driven physiological responses prompted us to integrate the ancient Indian ‘Isha Aum’ tool to the erstwhile module and study its effect to assist in bridging the gap between knowledge and behaviour. The ‘Isha AUM’ tool, described in the Indian veda and offered by Isha Foundation(31) as a tri-syllable tool using focus, breath and verbal techniques and is claimed as useful in establishing change in behaviour through psycho-physiological improvement.

To elicit the effect of combining Isha AUM with WOP, in bringing about the necessary change in the hydration status and psycho-physiology, 18-22 years old male collegiate hockey players, training with the Government of India were studied with the same research design as our previous study(27b), using WOP as the controlled intervention and IshaAum WOP as the experimental intervention (Isha Aum was implemented in EG for 21 days). All physiological, PPP and KAP related parameters were assessed pre and post interventions and the rating scale assessment-used for spiritual and its related parameters, made.

Changes in body hydration parameters after Isha AUM intervention

Paired sample t-test was applied to assess the changes in pre and post-exercise hydration status (USG and UpH) after initiation of Isha AUM (Table 16). There was a significant difference (p<0.01) observed in the pre- and post exercise USG where as only the post- exercise UpH was observed to be significantly (p<0.05)different in the EG. No change was observed in the control group.



Table 16: Changes in body hydration parameters within the EG and CG after Isha AUM

Pre (Mean ± SD) Post (Mean ± SD) Group

Parameter

Baseline measurement

After intervention measurement

t-value



t-value

EG 1.024±0.005N

S 1.013±.005 9.02** 1.026±0.005 1.018±0.009 9.28**

CG

USG

1.022±0.004N

S 1.023±.0005 0.32NS 1.027±0.002 1.027±.004 0.00 NS

EG 5.96± 0.441 6.06±0.177 1.00 NS 5.53 ±0.516 5.80±0.414 2.25*

CG

UpH

5.83±0.556 5.86±0.480 0.43 NS 5.60 ±0.507 5.53±0.516 1.00 NS

NS- Not significant; ** Significant at .01 level; * Significant at .05 level

When the hydration status of the two groups was compared(Table 17), the pre- exercise & post- exercise USG of the two groups(p<0.01) and the post- exercise UPH(p<0.05) revealed a significant difference indicating that the experimental group was better hydrated than the control group.

Table 17: Body hydration status of the EG and CG after Isha AUM initiation

Parameter Group Pre (Mean ± SD) t-value Post (Mean± SD) t-value

USG EG 1.013±0.005 1.018±0.004

CG 1.023±0.005

4.74**

1.027±0.004

6.19**

pH EG 6.06±0.175 5.80±0.414

CG 5.86±0.480

1.51 NS

5.53±0.516

1.56 NS

** Significant at .01 level; NS- Not significant

This study concluded that at baseline, the level of hydration was similar between both the groups but with the initiation of the BCC module with Isha AUM, in EG, their hydration status (USG level) was enhanced perhaps due to further improved practices whereas that of CG remained almost similar which contributed to the differences in the EG and CG’s USG measurement. This validates the need of including intervention such as AUM to the hydration education module for bringing about the improvement in hydration related behaviour to enhance hydration status.

Changes in Psycho-Physiological Parameters after Isha AUM initiation

Paired sample t-test was applied for EG as well as CG to assess the changes in pre and post exercise psycho-physiological parameters(p<0.01) after Isha AUM initiation (Table 18), while no change emerged in CG, which indicated Isha AUM may have enhanced the hydration status as well as improved the psychophysiological profile of subjects practicing it regularly.



Table 18: Changes in Psycho-Physiological parameters after Isha AUM initiation

**Significant at .01 level; NS- Not significant

Independent t-test was used to compare post- intervention, psycho-physiological parameters of EG and CG (Table 19).The data indicated that there was a significant difference for both the pre and post-exercise psycho-physiological parameters between the EG and CG with improved levels in EG which was perhaps linked with their improved hydration status after the 21 days implementation of Isha AUM initiation in this group.

To assess if hydration and psycho-physiology are related, the covariance between their parameters was calculated and since a positive covariance of USG and pH with SRT and CRT was observed, it indicates that the dehydration may be the reason for no change of psycho-physiological parameter in CG. Our previous studies have also indicated a positive covariance between USG and HR, and concluded that dehydration may have led to deterioration in the psycho-physiological profile particularly the HR(26, 26b) and this was supported by data of this study.

Table 19: Psycho-physiological profile of EG and CG after Isha AUM initiation

Parameter Group Pre (Mean ± SD) t-value Post (Mean± SD) t-value

HR EG 66.86±3.99 79.46±4.95

CG 71.66±5.23

2.82**

84.86±8.65

2.09**

SRT EG 0.250±0.02 0.303±0.01

CG 0.290±0.02

5.60**

0.339±0.03

4.01**

CRT EG 0.342±0.04 0.4141±0.04

CG 0.400±0.04

3.58**

0.561±0.04

7.43**

** Significant at .01 level

Thus it can be concluded that at baseline, the psycho-physiological status was similar in both groups but after implementation of the BCC module with Isha AUM, the psycho-physiological parameters of EG were enhanced, in combination with improved hydration status whereas that of CG remained unchanged.

Implementation of the rating scale to assess the changes in practices related to hydration and spiritual health

The comparison between baseline and post-intervention scores was carried out for hydration practices like fluid consumption before, during & after exercise and various perceived parameters like happiness, calmness, concentration, anger, fatigue in both groups.

Scores for various perceived parameters in EG and CG (Baseline)

Independent t-test was applied to compare the mean baseline scores between EG and CG (table 20). There was no significant difference in the baseline scores between EG and CG indicating both the groups were similar at baseline level in terms of various perceived parameters.

Pre (Mean ± SD) Post (Mean ± SD) Group

Parameter



t-value



t-value

EG HR 75.33±6.60 66.86±3.99 7.85** 86.80±6.16 79.46±4.95 6.98** CG 72.66±6.99 71.66±5.23 0.59NS 83.86±9.36 84.86±8.65 0.38NS EG SRT 0.297±0.01 0.250±0.02 9.15** 0.329±0.02 0.303±0.01 5.48** CG 0.300±0.02 0.290±0.02 1.93NS 0.329±.02 0.339±0.03 1.86NS EG CRT 0.426±0.44 0.342±0.04 7.31** 0.520±0.06 0.4141±0.04 8.68** CG 0.410±0.02 0.400±0.04 0.76NS 0.558±0.03 0.561±0.04 0.29NS



Table 20: Scores for various perceived parameters in EG and CG (Baseline)

Baseline scores

Parameters

EG CG

t-value

Hydration practices Fluid consumption before exercise 3.13 ±0.915 2.8 ±0.836 0.43 NS Fluid consumption during exercise 2.40 ± 1.140 2.8± 0.547 0.63 NS Fluid consumption after exercise 4.80± 0.836 4.8±0.0.836 0.31 NS Perceived positive parameters

Happiness 7.13 ± 1.355 7.33 ± 1.046 0.45NS Calmness 5.80 ± 1.082 6.00 ± 1.253 0.46 NS

Concentration 6.20 ± 1.207 6.40 ± 1.183 0.45 NS Awareness regarding thirst 4.00 ± 0.925 3.86 ± 0.743 0.43NS

Sports Performance 6.60 ± 0.828 6.60 ± 0.728 0 Perceived negative parameters

Stress 6.46 ± 1.355 6.20± 1.420 0.64 NS Fatigue 4.40 ± 1.594 4.80 ± 1.521 0.70 NS Anger 5.20 ± 1.320 5.66 ± 1.397 0.94 NS

NS: Non significant

To assess the change in scores after AUM initiation (Table 21), Paired sample t-test was applied. Significant difference (p<0.01) between the pre and post intervention scores was obtained for the EG, indicating marked improvement in their hydration practices and self- rated happiness, calmness and sports performance. Their awareness regarding thirst had increased which was may be one reason for their improved hydration status and their level of stress, fatigue and anger was decreased. No significant difference was observed in CG who did not practice Isha AUM.

Table 21: Differences in perceived parameters

Parameters Group

Baseline scores

After intervention Scores

t-values

Hydration practices EG 3.13 ±0.915 7.73±0.883 12.68** Fluid consumption before exercise CG 2.8 ±0.836 5.0±0.707 3.31* EG 2.40 ± 1.140 7.20±0.447 8.23** Fluid consumption during exercise CG 2.8± 0.547 3.40±0.836 2.44 NS EG 4.80± 0.836 8.40±0.547 14.69** Fluid consumption after exercise CG 4.8±0.0.836 5.20±0.447 0.78 NS

Perceived positive parameters EG 7.13 ± 1.355 7.80 ± 1.041 3.56** Happiness CG 7.33 ± 1.046 7.13 ± 1.187 0.71 NS EG 6.00 ± 1.253 8.133 ± 0.833 10.0** Calmness CG 6.00 ± 1.253 5.866 ± 1.457 0.80 NS EG 6.20 ± 1.207 8.06 ± 0.798 7.89** Concentration CG 6.40 ± 1.183 6.40 ± 1.121 0 EG 4.00 ± 0.925 7.80 ± 0.861 14.51** Awareness regarding thirst CG 3.86 ± 0.743 4.46 ± 1.187 2.80 NS EG 6.60 ± 0.828 7.13 ± 0.915 3.28** Sports Performance CG 6.60 ± 0.728 6.80 ± 1.014 1.14 NS

Perceived negative parameters EG 6.46 ± 1.355 4.66 ± 0.975 6.08**

Stress CG 6.200 ±1.42 6.66 ±1.112 1.97 NS EG 4.40 ± 1.594 4.00 ± 1.309 2.44*

Fatigue CG 4.80 ±1.521 4.46 ±1.302 1.435 NS EG 5.20 ± 1.320 4.06 ± 1.099 5.90**

Anger CG 5.66 ±1.397 5.266 ±1.22 1.702 NS

** Significant at .01 level; * Significant at .05 level ;NS: Non significant



To compare the post intervention scores for various parameters between EG and CG independent t-test was applied (Table 22) which indicated a significant difference(p<0.01) between many parameters including their hydration practices, calmness, concentration, awareness regarding thirst, stress and anger.

Table 22: Scores for various perceived parameters in EG and CG after Isha AUM initiation

After intervention scores Parameters

EG CG

t-value

Hydration practices Fluid consumption before exercise 7.73±0.883 5.0±0.707 5.71** Fluid consumption during exercise 7.20±0.447 3.40±0.836 10.87** Fluid consumption after exercise 8.40±0.547 5.20±0.447 10.11**

Positive parameters Happiness 7.80±1.041 7.13 ± 1.187 1.65NS Calmness 8.13±0.833 5.86 ± 1.457 5.22 **

Concentration 8.06 ± 0.798 6.40 ± 1.121 4.68 ** Awareness regarding thirst 7.80 ± 0.861 4.46 ± 1.187 8.80**

Negative parameters Stress 4.66 ± 0.975 6.66 ±1.112 5.23**

Fatigue 4.00 ± 1.309 4.46 ± 1.302 0.97 NS Anger 4.06 ± 1.099 5.266 ±1.22 2.82**

** Significant at 0.01; NS: Non significant

This indicated that Isha AUM initiation brought improvement in various practices in EG which was the reason for their enhanced hydration status and thus psycho-physiology. Also, that such tools have several added benefits on physical(improved HR, lower stress levels ); Mental (GSR, SRT, CRT, focus, concentration);emotional (Calm or peace, sense of well being, less anger, improved relations) and Energy(Energetic, lighter, efficient) parameters. Integrated enhancement of these parameters naturally aids in maximal athletic performance – the ultimate goal of all training, hence, tools such as Isha AUM may be useful in enhancing the inner potential of the athlete to make necessary changes in his lifestyle, to support improved hydration as well as improved sports performance.

In conclusion, our studies(26, 26b, 27, 28, 34, 35) indicate that exercise and heat induced subtle dehydration, may affect PPP and including ancient tools such as Isha AUM to the erstwhile strategies helps bring out the necessary change in hydration behaviour. Further, since Isha AUM is described as an ancient Indian tool used in spirituality and yoga, the spiritual component of health, as proposed by WHO(32,33)may be the missing link between awareness, intention and empowerment to change.

References:

1. Gisolfi CV, Summers RW, Schedl HP. Intestinal absorption of fluids during rest and exercise.In: Perspectives in exercise science and sports medicine, Vol. 3.Fluid homeostasis during exercise. C.V Gisolfi and Lamb DL. Benchmark Press, Inc, 1990: 129-180.

2. Valentine V. The Importance of Salt in the Athlete's Diet. Current Sports Medicine Reports 2007;6 (4):237-240.

3. Maughan RJ, Shirreffs SM. Dehydration and rehydration in competitive sport. Scandinavian Journal of Medicine & Science in Sports 2010;20(3):40-47.

4. Murray R. Hydration and physical performance. J Am Coll Nutr. 2007;26:542S-548S. 5. Paik IY, Jeong MH, Jin HE, et al. Fluid replacement following dehydration reduces oxidative stress

during recovery. Biochem Biophys Res Commun. 2009 22;383(1):103-7. 6. Yuko T, Kazuhiro S, Kai T, et al. Exercise-Induced Oxidative DNA Damage and Lymphocytopenia in

Sedentary Young Males. Medicine and Science in Sports and Exercise 2008;40(8)1455-1462. 7. Sharp RL. Role of sodium in fluid homeostasis with exercise. J Am Coll Nutr 2006;25 :231S –239S. 8. Montain SJ. Hydration Recommendations for Sport. Current Sports Medicine Reports 2008;7(4):187-192. 9. Dougherty KA, Baker LB, Chow M, Kenney WL. Two percent dehydration impairs and six percent

carbohydrate drink improves boys basketball skills. Med Sci Sports Exerc. 2006;38:1650 –1658. 10. Rehrer NJ, Burke LM. Sweat losses during various sports. Aust J Nutr Diet 1996;53:S13 –S16.



11.Murray R. Hydration and physical performance. J Am Coll Nutr. 2007;26:542S- 548S, 2007; 12.Passe DH, Horn M, Stofan J, Horswill C, Murray R. Voluntary dehydration in runners despite

favorable conditions for fluid intake. Int J Sport Nutr Exerc Metab. 2007 ;17(3):284-95. 13. Greenleaf JE. Problem: thirst, drinking behavior, and involuntary dehydration. Med Sci Sports Exerc

1992;24 :645 –656. 14 Pitts GC, Johnson RE, Consolazio FC: Work in the heat as affected by intake of water, salt and

glucose. Am J Physiol 1944;142 :253 –259. itts et al, 1944). ) 15 Osterberg KL, Pallardy SE, Johnson RJ, Horswill CA. Carbohydrate exerts a mild influence on fluid

retention following exercise-induced dehydration. J Appl Physiol 2010;108:245-250. 16. Rodriguez NR, DiMarco NM, Langley S. Position of the American Dietetic Association, Dietitians of

Canada, and the American College of Sports Medicine: Nutrition and athletic performance. J Am Diet Assoc. 2009;109(3):509-27.

17 Singh R. Nutritional requirements of athletes exercising in a hot environment.Mal J Nutr.2005; 11(2): 189-198.

18.Singh R, Saat M, Sirisinghe RG, Nawawi M. Rehydration with fresh young coconut water, carbohydrate-electrolyte beverage and water following exercise-induced dehydration. Can J Appl Physio 2001;2:267-268.

19 Thomas R, Barry D, Warren G. Thermoregulation in elite athletes. Current Opinion in Clinical Nutrition & Metabolic Care 2006;9(6):666-671.

20 Lorenzo S, Halliwill JR, Sawka MN, Minson CT. Heat acclimation improves exercise performance. J Appl Physiol. 2010;109(4):1140-7.

21. Indian Council of Medical Research. Nutrient requirements and Recommended Dietary Allowances for Indians. A Report of the Expert group of ICMR 2010.

22 Hydration guidelines for excellence in sports performance. National Institute of Nutrition, International Life Sciences Institute of India, Sports Authority of India, 2006.

23. Armstrong LE, Maresh CM. Fluid replacement during exercise and recovery from exercise. Body Fluid Balance: Exercise and Sport. New York, NY: CRC Press; 1996:259 –281.

24. American College of Sports Medicine. ACSM Position Stand on Exercise and Fluid Replacement. Med Sci Sports Exerc 2007;39:377-390.

25. Casa DJ, Armstrong LE, Hillman SK, et al. National Athletic Trainer’s Association Position Statement: Fluid Replacement for Athletes. J Athl Train 2000:35(2):212-224.

25.Lal P R.Nutritional Requirements for Sports Persons, Journal of Indian Dietetic Assoc 2006;31,1-7. 26.Kataria I, Sahni S, Lal PR. Effect of body hydration status on the psycho-physiological profile of

college level women basketball players(18-22 years). British journal of Sports Nutrition 2010; 44 (suppl I). 26b.Kataria I, Lal P R, Sahni S. Effect of hydration status on psychophysiological profile of athletes.

Lambert Academic Publications, Germany 2012 ISBN 978 – 3 – 659 – 11181 – 5 (book168 pages). 27.Oberoi A, Lal P R, Effect of hydration with three popular fluids on the psychophysiology of collegiate

women basketball players. Proceedings of ISSN,Sep27-30 Kualalumpur 2010 Malaysia(abstract). 27b.Oberoi A, Lal P R. Effect of a fluid replacement strategy on the hydration status and

psychophysiology of collegiate(18-22years) basketball players. Proceedings of the annual meeting of the Indian Dietetic Association, Sep 2011(full article).

27c.Wadhwa E and Lal P R. Effect of hydration status and psychophysiological parameters on the injury status of athletes. M.Sc. thesis, department of Food and Nutrition, Lady Irwin College.2012(unpublished).

28.Aggarwal A, Lal P R. Education with Isha Aum in the improvement of psychophysiology and hydration practices of athletes. July 2012, Book Published by Lambert Academic Publication.

29 Gedrich K. Determinants of nutritional behaviour: a multitude of levers for successful intervention. Research Report 25th anniversary Symposium of AGEV 2003;41:231-238.

30. Brug J, Oenema A, Ferreira I. Theory, evidence and intervention mapping to improve behaviour nutrition and physical activity interventions. International journal of Behavioural Nutrition and Physical Activity 2005;2.

31.Vasudev SJ. Mystic’s Musings. 1st ed. Wisdom Tree Press, 2007. 32.WHO. Ottawa Charter for Health Promotion, adopted by the International Health Promotion

Conference, Ottawa, 21 November, 1986. 33. ϋstϋn B, Jakob R. Re-defining ‘Health’. Bulletin World Health Organisation 2005;83:802. 34. Aggarwal A, Lal P R. Effect of Isha Aum on the psychophysiology and hydration practices of

athletes. Proceedings of the annual meeting of the Indian Dietetic Association, Sep 2012(full article). 35. Priti Rishi Lal, Aanchal Agarwal and Bhavani Balakrishnan. Nutrition education with Isha Aum and

improvement in psychophysiology, hydration status and hydration practices of collegiate hockey players.Paper presented at the Food Studies Conference, University of Illinois, Urbana Champaign, USA



Applications of salivary biomarker measures in sport science

McKune A. J.

Discipline of Biokinetics, Exercise and Leisure Sciences, University of KwaZulu-Natal, Durban, South Africa

Introduction

Saliva testing is a relatively new methodology that sport scientists can use to accurately and effectively measure and monitor athlete biomarkers that represent their health status, physiological and psychological state relating to training, competition and other environmental stressors. Saliva samples are easy to take and the method is non-invasive with sport scientists able to take saliva samples anywhere from individuals of all ages in the laboratory or the field (1, 2). The non-invasiveness of saliva collection and analysis is a crucial advantage over blood-derived biomarker measures and ensures compliance in athletes (3). Research has shown that saliva testing is preferred to blood sampling, and is considered most convenient and more comfortable compared to blood and urine (4). Therefore, saliva biomarker profiling is finding its place as a useful tool in talent identification, athlete development and high performance programmes.

Sport Science and Saliva Biomarkers

Importantly, for sports scientists, saliva has been shown to contain important biomarkers that can be used to evaluate the health and performance of athletes. The discussion below will focus on sIgA and testosterone as these have shown to be particularly useful for examining health, predicting performance and evaluating recovery and coaching interventions.

Monitoring Mucosal Immunity

Immunoglobulins (Ig) are the major components of the adaptive humoral and mucosal immune system. Depending on the Ig isotype measured (5) moderate physical activity either stimulates or has no effect on Ig, whereas heavy exercise or periods of intense exercise training are associated with the suppression of Ig levels (5). This relationship has been demonstrated for sIgA in the saliva. sIgA is the most prominent Ig isotype in the airways where it serves as a first line of defence by neutralizing pathogens and inhibiting their adhesion to the mucosa (6). In athletes, there is limited research demonstrating a direct cause and effect relationship between low sIgA and illness, however it can be viewed as a risk factor for developing upper respiratory tract infections (URTI’s) (7). The measurement of sIgA has been shown to be useful for monitoring the health of athletes and predicting URTI’s during periods of heavy training and/or competition. For example, Neville et al. (2008) reported that elite professional sailors had a 48% chance of contracting an URTI within three weeks if sIgA fell to less than 40% of their mean healthy value (7). Fahlman et al. (2005) demonstrated that a low secretion rate of sIgA 40 µg·min-1 was a unique predictor of the number of URTIs throughout the course of an American competitive football season of 12 months’ duration (8). Recently, a study by Morlatti et al. (2012) examined the effect of a 20-day period of competition on sIgA and URTI’s in elite young male soccer players. The results demonstrated that a decrease in sIgA predicted URTI’s and the authors concluded that the monitoring of sIgA is a useful approach for predicting URTI occurrences in young athletes during short-term competitions, especially if frequent sampling and rapid measurements are made (9).

Monitoring Salivary Hormones

Research has shown that saliva is possibly the best medium for detecting the subtle hormonal changes associated with stress, recovery and mal-adaptation to training in athletes. Regular saliva hormone testing can provide a functional representation of the day to day effect of training and competition on an athlete. Weekly saliva hormone monitoring allows for the identification of trends and patterns that are developing in athletes over the season.



Importantly, measurement of salivary hormones may be a promising for talent identification programmes as indicated through the findings of a recent study by Cook et al. (2012). The authors found that salivary measurement of testosterone was effective in differentiating between elite and non-elite female athletes (young adults). Specifically, baseline free testosterone concentrations of a mixed group of elite female athletes were consistently more than double (112% higher) than those of a comparative non-elite group over a prolonged period of training and competition (10). Higher baseline testosterone may indicate a greater capacity for performance at higher work rates, which is commensurate with the demands of elite sport and a greater motivation to train. In addition, the link between testosterone and sporting potential could be mediated by behavioral mechanisms. Previous work identified that female testosterone levels are related to risk aversion (a possible indicator of competitiveness) (11), and to self-reported dominance (12), with high testosterone females also achieving higher dominance scores than those with lower testosterone (13). Arguably, the expression of dominance-related behaviors in sport may help to differentiate elite from non-elite athletes. Further research is required to examine the efficacy of measuring salivary hormones as part of talent identification programmes in younger individuals.

Research has also shown the importance of the salivary testosterone response to training workouts in predicting subsequent performance in professional rugby league competition (14). Specifically, the authors demonstrated that hormone response to a mid-week workout provided an early sign of team readiness to compete as well as recovery rate. Measurement of the salivary hormone response to training may therefore be a novel method for implementing training or management strategies to improve competition outcomes.

Measurement of salivary hormones has also been shown to be useful for examining the effects of different pre-match motivational interventions and post-match recovery interventions on subsequent athlete game performance (15, 16). Specifically, presentation of specific video footage combined with different coach feedbacks influenced free hormonal state and game performance several days later. Finally, the presentation of short video clips can be used to alter salivary testosterone concentrations as well as subsequent voluntary squat performance. Specifically, relative changes in testosterone concentration differed depending on the video-clip shown to athletes pre-workout. These changes were then demonstrated to modulate behavioural aspects and athlete performance (17).

Conclusions

Therefore, it is recommended that sport scientists include saliva biomarker measurement as part of their athlete talent identification and monitoring systems in their development and high performance programmes. Saliva sampling is non-invasive, stress-free and is easily performed in a participant's natural settings. Importantly, sampling can be repeated over time, within and between days, and has a number of logistical advantages over venepuncture. These factors are crucial as with all sport science testing and monitoring there needs to be continuity and consistency over time for athlete profiles to be developed, predictions to be made and efficacy to be assessed.

References

1. McKune AJ, Du Bose K. Relationship between salivary androstenedione, body composition and physical activity in young girls. Journal of Endocrinology, Metabolism and Diabetes of South Africa. 2012;17(1):44-50.

2. McKune AJ, Smith LL, Semple SJ, Wadee AA, Fickl H, Villa JG, et al. Changes in mucosal and humoral atopic-related markers and immunoglobulins in elite cyclists participating in the Vuelta a Espana. Int J Sports Med. 2006 Jul;27(7):560-6.

3. Caruso JF, Lutz BM, Davidson ME, Wilson K, Crane CS, Craig CE, et al. Salivary hormonal values from high-speed resistive exercise workouts. J Strength Cond Res. 2012 Mar;26(3):625-32.

4. Koka S, Beebe TJ, Merry SP, DeJesus RS, Berlanga LD, Weaver AL, et al. The preferences of adult outpatients in medical or dental care settings for giving saliva, urine or blood for clinical testing. J Am Dent Assoc. 2008 Jun;139(6):735-40.

5. Mackinnon LT. Immunoglobulin, antibody, and exercise. Exerc Immunol Rev. 1996;2(1-35). 6. van Egmond M, Damen CA, van Spriel AB, Vidarsson G, van Garderen E, van de Winkel JG. IgA and the

IgA Fc receptor. Trends Immunol. 2001 Apr;22(4):205-11. 7. Neville V, Gleeson M, Folland JP. Salivary IgA as a risk factor for upper respiratory infections in elite

professional athletes. Med Sci Sports Exerc. 2008 Jul;40(7):1228-36. 8. Fahlman MM, Engels HJ. Mucosal IgA and URTI in American college football players: a year

longitudinal study. Med Sci Sports Exerc. 2005 Mar;37(3):374-80.



9. Mortatti AL, Moreira A, Aoki MS, Crewther BT, Castagna C, de Arruda AF, et al. Effect of competition on salivary cortisol, immunoglobulin A, and upper respiratory tract infections in elite young soccer players. J Strength Cond Res. 2012 May;26(5):1396-401.

10. Cook CJ, Crewther BT, Smith AA. Comparison of baseline free testosterone and cortisol concentrations between elite and non-elite female athletes. Am J Hum Biol. 2012 Nov-Dec;24(6):856-8.

11. Sapienza P, Zingales L, Maestripieri D. Gender differences in financial risk aversion and career choices are affected by testosterone. Proc Natl Acad Sci U S A. 2009 Sep 8;106(36):15268-73.

12. Sellers JG, Mehl MR, Josephs RA. Hormones and personality: testosterone as a marker of individual differences. J Res Pers. 2007;41(126-138).

13. Grant VJ, France JT. Dominance and testosterone in women. Biol Psychol. 2001;58:41-7. 14. Crewther BT, Sanctuary CE, Kilduff LP, Carruthers JS, Gaviglio CM, Cook CJ. The workout responses of

salivary-free testosterone and cortisol concentrations and their association with the subsequent competition outcomes in professional rugby league. J Strength Cond Res. 2013 Feb;27(2):471-6.

15. Cook CJ, Crewther BT. The effects of different pre-game motivational interventions on athlete free hormonal state and subsequent performance in professional rugby union matches. Physiol Behav. 2012 Jul 16;106(5):683-8.

16. Crewther BT, Cook CJ. Effects of different post-match recovery interventions on subsequent athlete hormonal state and game performance. Physiol Behav. 2012 Jun 25;106(4):471-5.

17. Cook CJ, Crewther BT. Changes in salivary testosterone concentrations and subsequent voluntary squat performance following the presentation of short video clips. Horm Behav. 2012 Jan;61(1):17-22.



The eye in sporting activities

Ong K.

Ophthalmic Surgeon University of Sydney Royal North Shore Hospital, Ryde Hospital, Dalcross Adventist Hospital Australia

General physicians and sports physicians will often be the first contact with patients regarding sports, and ophthalmologists only see the patient when referred. Hence, it is hoped that this talk would be informative and useful in optimising eye care for patients.

When we talk about sporting activities, we mean physical exertion usually outdoors. Therefore, when someone does physical exertion such as in dancing, playing certain musical instruments, gardening or physical work, the following may also apply.

This talk will be divided into 3 sections: (A) Ophthalmic conditions that may have implications for sporting activities (B) Healthy eye and sporting activities (C) Eye injuries in sporting activities.

(A) Ophthalmic conditions that may have implications in sporting activities

1. Evolving posterior vitreous detachment: A patient who complains of recent flashes/floaters should be examined by an ophthalmologist for retinal

tears, holes and detachment, and advised to avoid jerky head movements until the flashes settle. Hence, as there are usually jerky head and eye movements in sporting activities, it should be avoided. Reading a book may also cause jerky eye movements due to saccades when scanning the page, and hence, should be minimised or avoided.

When young, the vitreous is attached to the retina. With age, the vitreous may shrink and move forward, and so causes traction on the retina. This can result in retinal tear and hole formation in a small percentage of cases.

The retina is like a wallpaper attached to the inside of the globe with hydrostatic pressure and vacuum. When there is a break in the retina, fluid enters the subretinal space and this then leads to retinal detachment.

Jerky head movements increase vitreo-retinal traction, and hence, increases the risk of retinal hole formation.

2. Recent intraocular surgery: In cataract surgery, the wound is usually sutureless now. Putting pressure on the corneal wound edges

may cause the wound to open and leak aqueous. Hence, it is important to prevent blunt trauma or rubbing the eye for a few weeks, as this may open the surgical wound.

In glaucoma surgery, a fistula is created to allow aqueous to drain from the anterior chamber to the space and tissues between the conjunctiva and sclera. In the first few weeks, putting pressure on the eyeball may cause too much fluid to drain out. It is important to avoid activities that may raise intraocular pressure such as pressing on the eyeball, forcible lid closure, weight lifting, wearing small swimming goggles, etc.

There is usually associated posterior vitreous detachment. Hence, it is important to avoid jerky head and eye movements as well.

3. Glaucoma and excessive water drinking: After exercise, one usually feels thirsty due to loss of water through perspiration. Hence, there is a desire

to drink a large volume of water. When one drinks more than 2 glasses of water (500 ml) within an hour, there is a risk of causing intraocular pressure rise, especially in a patient who has glaucoma.

Hence, advise glaucoma patients not to drink more than 2 glasses of water in an hour, ie spread or space out the water intake.

4. Glaucoma surgery and swimming: In glaucoma surgery, a fistula is created to drain the aqueous from the anterior chamber to under the

conjunctiva (that is subconjunctival tissue). Sometimes, the conjunctiva can be quite thin. This means that the



barrier between the inside of the eye and the outside world is the thin conjunctiva, rather than sclera and conjunctiva or cornea.

Hence, if a patient who has a thin filtration bleb after glaucoma surgery swims in water that has a significant bacterial count and gets a bacterial conjunctivitis, this can potentially lead to endophthalmitis which can be a devastating infection of the eye.

5. Swimming goggles and Glaucoma: Morgan et al (2008) and Ma et al (2007) reported the rise of intraocular pressures when wearing small

swimming goggles. Hence, swimming goggles should be over the orbital margin and not press on the eye or eyelid tissue within the orbital margin.

6. Yoga and Glaucoma: During Yoga head stands, the intraocular pressure can rise two-fold. Baskaran et al (2006) and Gallardo

et al (2006) reported on the rise of intraocular pressure and progression of glaucoma with Sirsasana (head stand) yoga posture. This is probably due to increased episcleral venous pressure and increased choroidal volume from vascular engorgement. Hence, advise patients with glaucoma to avoid yoga head stands.

7. Herpes simplex keratitis and UV light When the Herpes Simplex virus infects the cornea, the virus can become a chronic problem. The virus

can remain inactive for many years and UV light can reactivate the virus. Hence if a patient who has a history of herpes simplex keratitis, spends a lot of time outdoors in the sun playing sports, there is a risk that it may contribute to recurrent herpes simplex keratitis.

8. Acute conjunctivitis and swimming Viral conjunctivitis can be spread by tears. If patients with viral conjunctivitis contaminate their fingers

with their tears and then touch door knobs, other people who touch the door knobs and then their eyes can transfer the virus to their eyes.

Patients with acute conjuncitivitis, especially viral and Chlamydia may contaminate the water in a swimming pool. This can be contagious to other users of the swimming pool.

(B) Healthy eye and sporting activities

1. Sore eyes after swimming – use tear supplements or wear goggles The tear film consists of 3 layers – lipid, aqueous and mucin layers. It has electrolytes and other

components that help to keep the pH constant. When swimming, the ocular surface is bathed with swimming pool water which may be of a different pH besides containing chlorine. This can cause ocular irritation. To help this problem, the use of tear supplements can be used before and after swimming. Taking omega-3 flax seed or fish oil can also help improve the tear film.

If pool water is not well maintained, the water may harbour bacteria and viruses. Hence, may need to use topical antibiotics (Chloromycetin, Tobrex) if acute conjunctivitis is present.

2. Avoid or minimise UV light exposure – Ultraviolet light may contribute to pterygium/pingueculae and cataract formation and also macular degeneration. Hence, wear sunglasses, and avoid sun exposure around midday. We should be aware of additional exposure due to reflected light from snow in skiing and from water in water sports.

3. Wear eye protection, especially if they have only one good eye, ie the other eye blind or amblyopic. Eye injuries may occur when least expected. Certain sports such as squash may have a higher risk of eye injury.

4. Contact lenses versus glasses for sporting activities. Glasses may be better as they may protect the eye from blunt trauma or dust. If a tennis ball or badminton shuttlecock hits the eye, the eye can sustain significant blunt trauma. In someone who wears glasses, the spectacles would take some of the impact and may transmit some of the forces to the nose and cheek. This will probably cause bruising, rarely a fracture. If the spectacle lenses break, the broken glass or plastic may cut the eye; but it would be less traumatic than a severe blunt trauma causing a rupture of the globe.

5. Patients with poor tear film, may get stingy eyes if sweat gets into the eyes as the sweat has a different composition and pH to tears. Lid hygiene may help. Omega 3 fish oil or flaxseed oil can improve the tear film and improve the buffering properties, and thus prevent this problem.

6. Mountaineering and High Altitude Retinopathy: Mountaineers who climb over 5,000 metres above sea level may get retinal haemorrhages (High Altitude

Retinopathy). Barthelmes et al (2011) and Wiedman and Tabin (1999) described the appearance of retinal haemorrhages in altitudes above 5000m. If the retinal haemorrhages occur over the macula, vision may be compromised.



(C) Eye injuries in sporting activities

When assessing a patient with acute ocular trauma, it is important to routinely check and record visual acuity besides looking for the physical signs of eye injury. Besides the eye, the eyelids and orbit may also sustain trauma. Orbital floor blowout fractures usually cause restriction of eye movements and bruising of periorbital tissue. Hence, it is important to check for ocular movements and integrity of eyelid tissue.

Macewen (1987) did a survey of sport associated eye injury in a casualty department in Glasgow Eye Infirmary, which described injuries from football, rugby, squash, badminton, skiing and other sports.

1. Corneal-conjunctival abrasions – corneal and conjunctival abrasions can result from contact with the ball, racquet or finger. Fluorescein staining shows up corneal or conjunctival epithelial defects. A sharp edge may cause corneal or conjunctival lacerations or even a penetrating eye injury. A full thickness penetrating injury can cause iris prolapse with the iris plugging the hole. Conjunctival-subconjunctival haemorrhage may also be present.

2. Corneal wound and iris prolapse – we can evaluate for this by looking for any black tissue protruding from the cornea or conjunctiva-sclera. If there is iris prolapse,, the pupil is usually not circular, probably peaked at one edge.

3. Hyphaema – hyphaema may be microscopic or macroscopic. The blood may come from torn iris or uveal tissue. Initially the aqueous is mixed with blood and hence, one sees a hazy view of the pupil and iris. When the blood settles, then one can see the blood level. The slit lamp microscope is needed to evaluate for microscopic hyphaema.

4. Traumatic iritis: This is common after a blunt injury. There is low grade iritis, and may be associated with traumatic mydriasis.

5. Traumatic mydriasis - The sudden stretching of iris can paralyse the sphincter pupillae. Usually it takes a few days to recover. However, if there is actual tearing of iris sphincter, then pupil constriction may be compromised in the future and pupils may be unequal in size.

6. Traumatic iridodialysis – sudden compressive force of the eyeball anterior-posteriorly, causes stretching-expansion around the equator, and this can tear the iris at its root causing iridodialysis. There is usually associated hyphaema and the iris-pupil is out of shape.

7. Acute glaucoma - this may be associated with hyphaema. The red blood cells block the trabecular meshwork, and restricts aqueous outflow; hence a rise of intraocular pressures.

8. Scleral rupture – this usually appears as black tissue in the white of the sclera. However, it can be difficult to evaluate for this if there is significant conjunctival and subconjunctival haemorrhage. Posterior scleral rupture may be difficult to detect

9. Damage to Lens and Zonules - In significant blunt trauma, zonules may be torn and this can cause phacodenesis or lens dislocation-subluxation. Cataracts may also form after trauma to the lens.

10. Retinal oedema and haemorrhage - Shock waves to the retina can cause commotio retinae. There is retinal oedema and a relative scotoma may be present on visual field testing. Vitreoretinal traction may cause retinal haemorrhage and retinal tear-hole-detachment formation.

There is risk of expulsive haemorrhage in severe blunt trauma especially if there is prolonged hypotony after rupture of the globe. Sudden haemorrhage pushing out the contents of eye (retina and uvea) through wound in sclera or cornea, makes salvaging the eye not possible. Sympathetic ophthalmia is rare and can occur after severe trauma. The severely injured eye is usually blind, and the patient complains of glare and pain in the good uninjured eye. This is due to auto-immune induced inflammation by antigens released from the injured eye.

There may be long term possibility of glaucoma due to damage to trabecular meshwork if angle recession is present. Stretching of the tissues of the trabecular meshwork can lead to scarring. When young the trabecular meshwork is efficient, so if 50% of the trabecular meshwork is scarred, the efficient other 50% may be sufficient. With age, especially when there is a tendency or family history of glaucoma, the trabecular meshwork can become less efficient, and hence, the remaining 50% becomes insufficient and so intraocular pressure rises. Unilateral glaucoma can be due to previous trauma.

Summary

This talk has provided an overview of eye conditions that may have implications in sporting activities. Aspects of sporting activities that may concern the healthy eye were discussed. With regard to eye injuries in sports, prevention is better than cure. Protective eyewear is important, and spectacles do offer some protection. Hence, it may be preferable to wear spectacles instead of using contact lenses or have laser refractive surgery.



References:

Barthelmes D, Bosch MM, Merz TM, Petrig BL, Truffer F, Bloch KE, Holmes TA, Cattin P, Hefti U, Sellner M, Sutter FK, Maggiorini M, Landau K (2011): Delayed Appearance of High Altitude Retinal Hemorrhages. Plos one: www. Plosone.org. February 2011, Volume 6, Issue 2.

Baskaran M, Raman K, Ramani KK, Roy J, Vijaya L, Badrinath SS (2006): Intraocular pressure changes and ocular biometry during Sirsasana (headstand posture) in yoga practitioners. Ophthalmology, 2006 Aug; 113 (8): 1327-1332.

Gallardo MJ, Aggarwal N, Cavanagh HD, Whitson JT (2006): Progression of glaucoma associated with the Sirsasana (headstand) yoga posture. Adv Ther. 2006 Nov-Dec; 23 (6) 921-925.

Ma KT, Chung WS, Seo K, Seong GJ, Kim CY (2007): The effect of swimming goggles on intraocular pressure and blood flow within the optic nerve head. Yonsei Med J 2007 Oct 31; 48 (5) , 807-809.

Macewen CJ (1987): Sport Associated eye injury: a casualty department survey. British Journal of Ophthalmology, 1987, 71, 701-705.

Morgan WH, Cunneen S, Balaratnasingam C, Yu DY (2008): Wearing swimming goggles can elevate intraocular pressure. Br J Ophthalmolol 2008, 92, 1218-1221.

Wiedman M, Tabin GC (1999): High-altitude retinopathy and altitude illness. Ophthalmology 1999 Oct; 106 (10) 1924-1926.



Platelet-rich plasma: Facts and fallacies.

Shariff AH

Unit of Sports Medicine,Faculty of Medicine,University of Malaya Kuala Lumpur Malaysia

Platelet-rich plasma (PRP) is defined as plasma with a concentration of platelets above baseline value (peripheral blood). In addition to its main function in securing haemostasis, our understanding of platelets involvement in tissue healing have expanded over the last two decades. Platelets participation in tissue healing occurs via the release of various bioactive molecules (growth factors) stored within the α- and dense-granules that occurs upon activation (Table 1) [1]. These cytokines and growth factors influences cellular chemotaxis, cell migration, cellular mitosis, extracellular matrix production, and angiogenesis. Moreover, these bioactive molecules also signal cells to proliferate and influence maturation, differentiation and ultimately tissue repair [2].

Table 1: Growth factors in the α-Granules of platelets and their physiologic effect*

Growth factors Biologic activities

TGF-β Promotes matrix synthesis

PDGF Chemoattraction, cell proliferation

IGF-I, II Cell proliferation, maturation, bone matrix synthesis

FGF Angiogenesis, fibroblasts proliferation

EGF Cell proliferation

VEGF Angiogenesis

ECGF Endothelial cell proliferation, angiogenesis

TGF, transforming growth factor; PDGF, platelet-derived growth growth factor; IGF, insulin growth factor; FGF, fibroblast growth factor; EGF, epidermal growth factor; VEGF, vascular endothelial growth factor; ECGF, endothelial cell growth factor. Adapted from Foster et al, (2009)[1]

The two common methods of PRP preparation are the plasma-based and the buffy-coat based systems. Each method produces PRP that differs in quality including the amount of platelets, white blood cells (WBC) and growth factors [3].

Mishra et al, proposed a PRP classification systems that is based on its cellular contents [4]. PRP have been used in medicine since 1970 in various discipline including maxillofacial surgery, dental

implant, plastic surgery, orthopaedic, rheumatology and tissue engineering [5]. In the field of Sports Medicine, PRP used received a lot of attention after it was reported to have successfully used in treating knee ligament injury of two NFL professional players in 2009. Both players were allowed to return-to-play within 6 weeks [6]. Since then, several high profiles professional athletes were reported using PRP for their injuries.

Autologous blood and blood products including autologous condition serum (ACS), platelet rich plasma (PRP) and platelet-rich in fibrin matrix (PRFM) are currently used for their potential benefits in accelerating soft tissues healing (tendons, muscles and ligaments) despite limited clinical evidence [7].

Our literature review found effects of PRP were frequently studied on tendinopathies, including tennis elbow, Achilles and patellar tendinopathies.

In a cohort study of patient with long standing elbow pain (mean of 15 months) that failed to show any improvement with non-operative treatment. Patient who received PRP injection demonstrated significant improvement in their visual analog pain scores eight weeks after the intervention [8].

Since then several randomised controlled trial (RCT) has been conducted, that consistently demonstrated positive effects of PRP injections (Table 2).

More recently, a multicentre double blind RCT of 230 patients found patient treated with PRP showed significant improvement in pain score at 8 and 12 weeks. More over clinically success rates as measured by a ≥ 25% reduction in pain score over baseline, were found in PRP treated patient at 24 weeks (p=0.012) [9].



Only two RCTs explored the effects of PRP on Achilles tendinopathy (Table 2). The findings of these studies was less consistent, with each demonstrated significant and non-significant effects of PRP on the outcomes measures. Furthermore no RCT is currently available on the effect of PRP on patellar tendinopathy.

Only one pilot controlled trail of PRP on muscle healing was available at the time of this review [10]. The study was a non-randomised and non-blinded trial of professional athletes diagnosed with acute

second-degree muscle injury. Intervention group received ACS 2.5 ml of ACS injection administered every second day (mean 5.4 injections/athlete) until full recovery was achieved. Even though this study found a significant reduction in DRP among athletes treated with ACS (16.6±0.9 days vs. 22.3±1.2 days, p=0.001), the study design has been question [7,11,12] as it lacks robustness that may restricts interpretation of the findings with low methodological quality score [13].

More recently, a retrospective case control study of ten professional National Football League athletes with grade-I and-II muscle injuries reported no significant difference in the duration to RTP between PRP treated and control groups [14]. The design of the study and small number of patients participated in the study may affect on the generalizability of this study.

The efficacy of PRP therapy on soft tissue healing in humans remained unanswered. Currently there is some evidence to suggest beneficial effects of PRP for treating tennis elbow and acceleration of muscle recovery. However, the PRP effect on other tendinopathies is less evident.

Table 2: PRP studies on tendinopathies

Author Design Intervention Outcome Findings Tennis elbow Mishra & Pavelko, 2006

Cohort study

PRP injection vs. Bupivacaine injection

VAS score Modified Mayo elbow score

Significant pain reduction

Peerbooms et al., 2010

RCT PRP injection vs. Corticosteroid injection

VAS score DASH score

Significant pain reduction and better functional score

Thanasas et al., 2011

RCT PRP injection vs. AB injection

VAS score Liverpool elbow score

Earlier pain relief (6 weeks), No difference – long term

Creaney et al., 2011 RCT PRP injection vs. AB injection

PRTEE Equally effective in reducing PRTEE score

Achilles tendinopathy Gaweda et al., 2010 Case series PRP injection AOFAS score

VISA-A score US appearance

Significant improvement in all outcome measures

de Vos et al., 2010 RCT PRP injection vs. Saline injection

VISA-A score Patient satisfaction

No significant difference

de Almeida et al., 2010

RCT PRP injection vs. No injection

VAS score MRI appearance

Improve pain score immediately but no difference long term

Patellar tendinopathy Kon et al., 2009 Case

control PRP + physiotherapy vs. Physiotherapy

Tegner EQ-VAS SF-36

No significant difference

Filardo et al., 2009 Case series PRP injection Tegner EQ-VAS SF-36

Significant improvement from baseline

VAS, visual analog scale; RCT, randomised controlled trial; DASH, disability of arm, shoulder and hand; AB, autologous blood; PRTEE, patient-related tennis elbow evaluation; AOFAS, American Orthopedic Foot and Ankle Society; VISA-A, Victorian Institute of Sport Assessment-Ankle; US, ultrasound; MRI, Magnetic resonance imaging; EQ-VAS, EuroQol Visual analog scale; SF-36, Short form-36.



It should be reminded that currently available studies vary in their methodology; including type of injectable substance use (ACS, PRP and PRFM), preparation of injectable substance, dosages, frequency of injections, type of muscle injury and the follow-up period.

Developing and adopting a standardised method of PRP classification, treatment protocol and outcome measures assessments are imperative to allow accurate comparisons between studies.

Therefore the current evidence is insufficient to recommend for or against routinely using PRP in muscle injury. Studies using robust clinical design are needed to evaluate the efficacy of PRP for the treatment of muscle injury.

References:

1. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA (2009) Platelet-Rich Plasma: From Basic Science to Clinical Applications. Am J Sports Med 37: 2259–2272.

2. Hammond JW, Hinton RY, Curl LA, Muriel JM, Lovering RM (2009) Use of autologous platelet-rich plasma to treat muscle strain injuries. Am J Sports Med 37: 1135–1142.

3. DeLong JM, Russell RP, Mazzocca AD (2012) Platelet-Rich Plasma: The PAW Classification System. YJARS 28: 998–1009. doi:10.1016/j.arthro.2012.04.148.

4. Mishra A, Harmon K, Woodall J, Vieira A (2012) Sports medicine applications of platelet rich plasma. Curr Pharm Biotechnol 13: 1185–1195.

5. Anitua E, Andí I, Sanchez M, Azofra J, del Mar Zalduendo M, et al. (2006) Autologous preparations rich in growth factors promote proliferation and induce VEGF and HGF production by human tendon cells in culture. J Orthop Res 23: 281–286. doi:10.1016/j.orthres.2004.08.015.

6. nytimes.com (n.d.) nytimes.com. Available: http://www.nytimes.com. Accessed 28 January 2013. 7. Engebretsen L, Steffen K, Alsousou J, Anitua E, Bachl N, et al. (2010) IOC consensus paper on the use of

platelet-rich plasma in sports medicine. Bri J Sports Med 44:1072–1081. 8. Mishra A, Pavelko T (2006) Treatment of Chronic Elbow Tendinosis With Buffered Platelet-Rich Plasma.

American Journal of Sports Medicine 34: 1774–1778. doi:10.1177/0363546506288850. 9. Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, et al. (2013) Platelet-Rich Plasma

Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow: A Double-Blind, Prospective, Multicenter, Controlled Trial of 230 Patients. Am J Sports Med. doi:10.1177/0363546513494359.

10. Wright-Carpenter T, Klein P, Schaferhoff P, Appell HJ, Mir LM, et al. (2004) Treatment of muscle injuries by local administration of autologous conditioned serum: a pilot study on sportsmen with muscle strains. Int J Sport Med 25: 588–593.

11. Hamilton BH, Best TM (2011) Platelet-enriched plasma and muscle strain injuries: challenges imposed by the burden of proof. Clin J Sport Med 21: 31–36.

12. Andia I, Sanchez M, Maffulli N (2011) Platelet rich plasma therapies for sports muscle injuries: any evidence behind clinical practice? Expert Opin Biol Ther 11: 509–518.

13. Sherrington C, Herbert RD, Maher CG, Moseley AM (2000) PEDro. A database of randomized trials and systematic reviews in physiotherapy. Man Ther 5: 223–226.

14. Rettig AC, Meyer S, Bhadra AK (2013) Platelet-Rich Plasma in addition to rehabilitation for acute hamstring injuries in NFL players clinical effects and time to return to play. Orthop J Sport Med.doi:10.1177/2325967113494354.



Ramadan and Sports Performance

Singh R.

Lifestyle Science Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam, 13200 Kepala Batas, Penang, Malaysia Section: Sports Science - Subsection: Exercise Physiology

Introduction

Ramadan month is the ninth month of the Hijri calendar, where Muslims are prohibited to eat and drink between dawn and sunset, which usually last for 29 to 30 days. Thus, routine behavioral patterns such as dietary intake, sleep, training stimulus and social behavior are mostly affected during this period (1). This form of intermittent fasting is liable to have implications for training and sports performance, as shown in one survey on 16-years-old athletes, where 29% of the athletes surveyed indicated that their performance was poorer during Ramadan (2). This brief review looks at alteration in aerobic and anaerobic, two main aspects of athletic performances during Ramadan.

Aerobic Performance

Studies have shown that during Ramadan, measured maximal oxygen intake have shown not to be affected after 2 or 4 weeks of fasting (3) or in the performance of submaximal aerobic exercise (4). Similarly estimated VO2max has been reported as being unchanged during Ramadan in competitive runners (5) and elite Judokas (6). Running velocity and distance covered during shuttle running test also appears unaffected by Ramadan fasting (7-9).

On the other side, studies have shown that Ramadan fasting has an effect on aerobic performance. Sweileh et al. (10) noted some decreases in maximal oxygen intake during the first week of Ramadan. In an other study, total distance and maximum aerobic velocity during Yo-Yo test was reduced by 12% and 14% respectively in youth footballers (11) and time to complete a 3-km run was approximately 1% slower in adolescent footballers (12). Aziz and colleagues (13) using a cross-over design before and during Ramadan showed that the average distance covered during a 30 min time trial was reduced by ~4% during Ramadan compared to before Ramadan. Similarly, Stannard & Thompson (14) found that 4 out of 8 subjects were unable to complete the final 10min of a 30 min progressive cycle ergometer test during Ramadan. In footballers, Zerguini et al. (15) noted that at the end of Ramadan there was a 16% decrease in the distance covered during a 12 min run conducted at 2pm with partial recovery in distance covered 2 weeks after Ramadan. In 5000m running performance, Brisswalter et al (5) showed there was a 5% increase (slower) in 5000m times at the end of Ramadan but there was no change in the maximal aerobic power or their running efficiency.

These results show that Ramadan related deterioration in maximal aerobic performance of less than 10 min duration is not observed but with longer bout of endurance exercise there is some deterioration as effort continues. However, it remains unclear whether this decrease in performance is due to depletion of glycogen (liver) reserves, progressive dehydration or simply due to subject’s poorer motivation or a combination of these factors.

Anaerobic Power and Capacities

Ramadan fasting has shown to reduce anaerobic performance depending on the time the study is conducted. In short distance sprints, a study showed that 100m and 800m performances were affected by fasting (16). With regard to sprint times, Meckel et al. (12) showed a small 0.8% decrease in repeated 40m sprint and a 5.3% decrease in overall 40m sprint performance during Ramadan when conducted 13h after breakfast. Kirkendall & colleagues (9) reported a 2% increase in 30m repeated sprint times in Ramadan fasting footballers when conducted in the afternoon. Similarly Senegalese sprinters had a negative effect of fasting on 3 x 150m and 3 x 250m sprint performance (17). However, Tunisian Judokas could maintain their sprint speeds throughout most of Ramadan but were approximately 4% slower over 3-m, 10-m and 30-m at the end of Ramadan (6).

With reference to power output measures, peak power, mean power and maximal power of Wingate performance, appears to be essentially unaffected when tested in the morning during Ramadan (18, 19) but



anaerobic power was reduced greatly in the afternoon and evening when compared with the non-fasting control period (19, 20).

In terms of power output measure, maximum power test appear to essentially unaffected when tested in the morning during Ramadan but anaerobic power were substantially reduced when tested in the afternoon and evening.

Conclusion

Studies show that there are minor effects of Ramadan fasting on athletic performance if the athlete maintains intake of energy and macronutrient intake including fluids, continue a normal pattern of training and has sufficient sleep per night. It in inevitable that there will some fatigue during repeated performance of sprints or during prolonged aerobic exercise. In addition, perturbation do occur during the first week of Ramadan fasting and therefore it is advisable that at least two weeks before the start of Ramadan fasting appropriate coping strategies should be gradually introduced.

References

1. Ziaee V, Razaei M, Ahmadinejad Z, Shaikh H, Yousefi R, Yarmohammadi L, Bozorgi F. Behjiati MJ. The changes of metabolic profile and weight during Ramadan fasting. Singapore Med J. 2006;47:409-414.

2. Singh R, Hwa OC, Roy J, Jin CW, Ismail SM, Lan MF, Hiong LL, Aziz AR. Subjective perception of sports performance, training, sleep and dietary patterns of Malaysian junior Muslim athletes during Ramadan intermittent fasting. Asian J Sports Med. 2011;2:167-176.

3. Ramadan JM, Barac-Nieto M. Cardio-respiratory responses to moderately heavy aerobic exercise during the Ramadan fasts. Saudi Med J. 2000;21:238-244.

4. Ramadan J, Telahoun G, Al-Zaid NS, Barac-Nieto M. responses to exercise, fluid and energy balances during Ramadan in sedentary and active males. Nutrition 1999;15:735-739.

5. Brisswalter J, Bouhlel E, Falola JM, Abbiss CR, Vallier JM, Hausswirth C. Effects of Ramadan intermittent fasting on middle-distance running performance in well-trained runners. Clin J Sport Med 2011;21:422-427.

6. Chaouachi A, Coutts AJ, Chamari K, Wong DP, Chaouachi M, Chtara M, Roky R, Amri M. Effect of Ramadan intermittent fasting on aerobic and anaerobic performance and perception of fatigue in male elite judo athletes. J Strength Cond Res 2009;23:2702-2709.

7. Aziz AR, Slater GJ, Chia MYH, The KC. Effects of Ramadan fasting on training induced adaptations to a seven-week high-intensity interval exercise programme. Sci Sports 2012;27:31-38.

8. Guvence A. Effects if Ramadan fasting on body composition, aerobic performance and lactate, heart rate and perceptual responses in young soccer players J Hum Kinetics 2011;29:79-91.

9. Kirkendall DT, Leper JB, Bartagi Z, Dvorak J, Zerguini Y. The influence of Ramadan on physical performance measures in young Muslim footballers. J Sports Sci 2008; 26 (Suppl 3):S15-S27.

10. Sweileh N, Schnitzler A, Hunter GR, Davis B. Body composition and energy metabolism in resting and exercising Muslims during Ramadan fast. J Sports Med Phys Fitness 1992;32:156-163.

11. Hamouda O, Chtourou H, Farjallah MA, Davenneb D, Souissi N. The effect of Ramadan fasting on the diurnal variations in aerobic and anaerobic performance in Tunisian youth soccer players. Biol Rhythms Res 2011;1:1-15.

12. Meckel Y, Ismael A, Eliakim A. The effect of the Ramadan fast on physical performance and dietary habits in adolescent soccer players. Eur J Appl Physiol 2008;102:651-657.

13. Aziz AR, Wahid MF, Png W, Jesuvadian CV. Effects of Ramadan fasting on 60 min of endurance running performance in moderately trained men Br J Sports Med 2010;44:516-521.

14. Stannard SR, Thompson MW. The effects of participation in Ramadan on substrate selection during submaximal cycling exercise. J Sci Med Sports 2008;11:510-517.

15. Zerguini Y, Kirkkendall D, Junge A, Dvorak J. Impact of Ramadan on physical performance in professional soccer players. Br J Sports Med 2007;41:398-400.

16. Ben Salama F, Hsairi M, Belaid J, Achour N achour A, Nacef T. Food intake and energy expenditure in high school athletes before, during and after the month of Ramadan: effect of fasting on performance. Tunis Med 1993;71:85-89.

17. Faye J, Fall A, Badji L, Cisse F, Stephan H, Tine P. Effects of Ramadan fast on weight, performance and glycemia during training for resistance. Dakar Med 2005;50:146-151.

18. Abedelmalek s, Souissi N, Takayuki A, Hadouk S, Tabka Z. Effect of acute maximal exercise on circulating levels of Interleukin-12 during Ramadan fasting. Asian J Sports Med 2011;2:154-160.



19. Chtourou H, Hammouda O, Chaouachi A, Chamari K, Souissi N. The effect of time-of-day and Ramadan fasting on anaerobic performance. Int J Sports Med 2012;33:142-147.

20. Souissi N, Souissi M, Souissi H, Chamari K, Tabka Z, Dogui M, Davenne D. Effect of time od day and partial sleep deprivation on short-term, high-power output. Chronobiol Int 2008;25:1062-1076.



Obesity, physical activity among subjects with Intellectual Disabilities: Considerations to promote of the level of Physical activity

Subasi F.1.

Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Yeditepe University Adress for Correspondence: 26 Agustos Yerlesimi, Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Yeditepe University - 34755 Kayısdagı- Ataşehir- İstanbul/ Turkey E-mail address: [email protected] - Telephone number:+90216 5780000/3216 Fax number: +902165780496 - Section: Sport Sciences - Subsection: Adapted Physical Activity and Health Promotion

Obesity has been linked to a wide variety of health problems, including cancer, cardiovascular diseases, and diabetes mellitus (1-5). The rapid rise in the prevalence of obesity and overweight are increasing across Turkey (6-9) with the overall prevalence of obesity in adults being 18.6% in the year 1990. However, the prevalence of obesity was found to be 25.3% for Turkish males and 44.2% for Turkish females in the year 2001 (10). According to large multicenter nationwide major studies TEKHARF study carried out in 1990 and 2000 (Turkish Adults and Risk Factors Study) and TURDEP study in 1999 (Turkish Diabetes Epidemiology Study) looked at the prevelance of obesity, diabetetes and hypertension in Turkey. Despite differences in methodology of the studies the results indicated that the prevelance of the obesity and overweight continues to increase in our country as well as all over the world.

It was indicated in TEKHARF that BMI was used as an independent risk factor for CVD in men and the cardiovascular risk were found to be increasing 9% in every 1 kg/m² BMI increment (11,12). Obesity prevalence (BMI>29.9 kg/m²) was found to be 22% in TURDEP while in TEKHARF study it was found to be 21.1% among males and 43.0% in females (12). The results indicates also the importance of monitoring obesity nationwide and in different regions of the Turkey, because there is a great difference in socioeconomic status between the populations who live in different parts of the country. A study by Krassas (13) et al. investigated the prevalence of overweight and obesity among children and adolescents in the city of Thessaloniki, Greece and in the Kayseri area of Turkey. The results showed that the prevalence of overweight for Greek school children was 22.2% while that of Turks was 10.6%. The obesity prevalence was 4.1% and 1.6%, respectively while the total number of overweight and obese children were 26.3% and 12.2%, respectively (13). Childhood obesity is very worrisome because %70 of obese teenagers will remain obese in adulthood ( 14,15)

The prevalence of obesity in the population with Intellectual Disabilities ( ID) has been shown to be more common than in the general population (14-20). It was identified the rate of being obese ( BMI> 30.0 kg/ m²) and overweight ( BMI> 25.0 kg/ m²) as totally 20.7 % among individual with mild moderate ID ( n= 59, aged between 7-22 years, 13.83±2.44 years ) (16). In USA, overall, 15.6% of men and 25.1% of woman were obese ( older age, and gender, living in institute or home, degree of ID, having other impairments effect that ratio ( 17 ). In Europe, the prevelance of the obesity in children is 6.8%, and 3.5 % in France (15). The increasing prevalence of being overweight in children and in adolescents with ID is associated with reduced physical activity levels, having sedentary life style and lower fitness levels than general population (18,19) Mobility problems appear to be 14 times more frequent in people with ID (20,21) The increasing prevalence of over weight in children and adolescents with ID associate with reduced physical activity level (15, 22). Subasi et al. showed that the prevalence of the sports habit in the children with ID was 31.1 % for both genders and the vast majority of the children with mental disabilities were overweight or obese. It was also found that body mass index was statistically negative associated with sit-up, standing broad jump test scores, 50- dash running time among children with ID (16). Lack of opportunity for exercise, poor eating habits, too much passive recreations, as well as using antipsychotic medications contribute to this problem (22, 23).

Sedentary life style are common place for those with ID and the fitness levels have been found to be lower than for the general population (24,25). Also, various studies indicate that the high prevalence of obesity in children and adults is a result of a life style that increases obesity prevalence with age (26,27). Sports and Regular Physical Activity are meaningful and important in lives of many people, including those with ID. Effectively including persons with ID in sport and PA not only requires in dept knowledge of their physical skill,



physical fitness, social skill development, but also of their mutual retaltionship between cognitive and neurophysiological potential of them (28)..However, there is serious concern that the individuals with ID may not be receiving adequate levels of physical education (29). It was demonstrated also that the ratio of the regular physical activity habits in the children with ID was 23.5 % for both genders (30). Thus, it may be concluded that the barriers to participation in sports and PA among individuals with ID directly effects to PA profile. It is also be recognized that people with ID have reduced access to range of health promotion program . Access to health promotion and PA program has come under scrutiny (31). However, participation in sport and physical activity is often a challenge for people, especially children, with ID because of poor motor functioning, low motivation and difficulty in self monitoring. Therefore promoting physical activity level is likely to be complex (23). They need simple field –based methods which can be performed easily in classrooms and gymnasiums are solely for use by APA & APE (29). It may be suggested that successful application of behaviour modification techniques in homes, classrooms, and institutional settings has stimulated interest in the experimental analysis of procedures that might be used to teach parents, teachers, and others to apply those techniques themselves. Therefore, the health promotion program can involve both parents and teachers that includes encouraging and consulting them to promote leisure physical/sport activities for children with ID .

Determining factors associated with PA or inactivity may result in the development of effective interventions for promoting regular physical activity. Although the major problem to participate physical activity among subjects with ID, numerous theories and models can be used to promote a habit of regular physical activity. However, the development of activity interventions or promotion programs is difficult because no clear barriers/ facilitators have been identified through research (32,33).

In light of the literature; It can be concluded that inactive role models (teacher, family member), competing demands and time pressures, unsafe environments, lack of adequate facilities, insufficient funds, and inadequate access to quality daily physical education seem to be more prevalent among populations with special needs (29,34) . Overall, environmental and family factors seem to be more significant determinants of participation than characteristics of the children themselves (34 ) The long-term effects with regard to maintaining participation in sport activity have not yet been evidenced. The number of the studies on community based, well-designed and socially supported exercise-intervention programs seem to improve, but the size of the sample must have larger population, as well.

References 1. Dezenberg, C.V., et al., Predicting body composition from anthropometry in pre-adolescent children.

International Journal Obesity Related Metabolic Disorder, 1999. 23(3): p. 253-9. 2. Stouffer, K. and S.M. Dorman. Childhood obesity: a multifaceted etiology. International Electronic

Journal of Health Education, 1999. 2(2): p. 66-72. 3. da Veiga, G.V., P.C. Dias, and L.A. dos Anjos, A comparison of distribution curves of body mass index

from Brazil and the United States for assessing overweight and obesity in Brazilian adolescents. Revista Panamericana de Salud Pública, 2001. 10(2): p. 79-85.

4. Draheim, C.C., D.P. Williams, and J.A. McCubbin, Prevalence of physical inactivity and recommended physical activity in community-based adults with mental retardation. Mental Retardation, 2002. 40(6): p. 436-44.

5. Aarnio, M., Leisure-Time Physical Activity In Late Adolescence: A Cohort Study Of Stability, Correlates and Familial Aggregation In Twin Boys And Girls. Journal of Sports Science & Medicine, 2003. 2, Supplementum 2: p. 1-41.

6. Yumuk, V.D., et al., High prevalence of obesity and diabetes mellitus in Konya, a central Anatolian city in Turkey. Diabetes Reserach and Clinical Practice, 2005. 70(2): p. 151-8.

7. Gokcel, A., et al., High prevalence of diabetes in Adana, a southern province of Turkey. Diabetes Care, 2003. 26(11): p. 3031-4.

8. Onat, A., et al., Sex difference in development of diabetes and cardiovascular disease on the way from obesity and metabolic syndrome. Metabolism, 2005. 54(6): p. 800-8.

9. Yumuk, V.D., Prevalence of obesity in Turkey. Obesity Reviews, 2005. 6(1): p. 9-10. 10. Ersoy, C., et al., Comparison of the factors that influence obesity prevalence in three district

municipalities of the same city with different socioeconomical status: a survey analysis in an urban Turkish population. Preventive Medicine, 2005. 40(2): p. 181-8.

11. Satman, I., et al., Population-based study of diabetes and risk characteristics in Turkey: results of the turkish diabetes epidemiology study (TURDEP). Diabetes Care, 2002. 25(9): p. 1551-6.

12. Yalcin, B.M., E.M. Sahin, and E. Yalcin, Prevalence and epidemiological risk factors of obesity in Turkey. Middle East Journal of Family Medicine, 2004. 6(6): p. 1-11.



13. Krassas, G.E., et al., Prevalence of overweight and obesity among children and adolescents in Thessaloniki-Greece and Kayseri-Turkey. Pediatric Endocrinology Reviews, 2004. 1 Suppl 3: p. 460-4.

14. Subasi, F., et al., Onset of smoking behaviors and participation in leisure physical activities of Turkish adolescents attending vocational health schools International Electronic Journal of Health Education, 2006. 9: p. 81-91.

15. Salaun, L. and Berthouze-Aranda, S. Obesity in School Children with Intellectual Disabilities in France. Journal of Applied Research in Intellectual Disabilities 2011. 24, 333–340.

16. Subasi, F., Luleci, E., Mumcu, G., Koksal, L., Inal, S., Hey, W. A Health Promotion Model for Turkish Children with Mental Disabilities. 8. Annual Hawaii International Conference on Education. Honollu, Hawaii, USA, January 7-10, 2010

17. Rimmer, J.H., Yamaki, K. Obesity and intellectual disability. Mental Retardation Developmental Disabilities Research Review, 2006. 12(1):22-7.

18. Davis, K., Zhang, G. and Hodson, P. Promoting Health-Related Fitness for Elementary Students With Intellectual Disabilities Through Specifically Designed Activity Program. Journal of Policy and Practice in Intellectual Disabilities, 2011. 8 ( 2): 77–84.

19. Verel, S., F. Subasi, and T. Erbaydar. Factors Influencing body mass index among children and adolescents with mental retardation. in Proceedings of the 7th International Congress of Sports Medicine Association of Greece. 2004. Drama, Greece.

20. Hove, O., Weight survey on adult persons with mental retardation living in the community. Research in Developmental Disabilities, 2004. 25(1): 9-17.

21. Krahn, G.L., Hammond, L. and Turner, A cascade of disparities: health and health care access for people with intellectual disabilities. Mental Retardation and Developmental Disabilities Research Reviews, 2006. 12(1): p. 70-82.

22. Shea, S.E., Mental retardation in children ages 6 to 16. Seminars in Pediatric Neurology, 2006. 13(4): p. 262-70.

23. van Schrojenstein Lantman-de Valk, H.M.J., Health in People with Intellectual Disabilities: Current Knowledge and Gaps in Knowledge. Journal of Applied Research in Intellectual Disabilities, 2005. 18(4): p. 325-333.

24. Todd, T. and Reid, G. Increasing Physical Activity in Individuals With Autism. Focus on Autism & Other Developmental Disabilities, 2006. 21(3): p. 167-176.

25. Harris, N., et al., Prevalence of obesity in International Special Olympic athletes as determined by body mass index. Journal of the American Dietetic Association, 2003. 103(2): p. 235-7.

26. Fernhall, B., Physical fitness and exercise training of individuals with mental retardation. Medicine & Science in Sports & Exercise, 1993. 25(4): p. 442-50.

27. Calle, E.E., et al., Body-mass index and mortality in a prospective cohort of U.S. adults. The New England Journal of Medicine, 1999. 341(15): p. 1097-105.

28. Van de Vliet, P., Rintala, K. and Fro jd, J. et al. Physical fitness profile of elite athletes with intellectual disability. Scandinavian Journal Medicine Science & Sports, 2006.16: 417–425.

29. Davis, K., Zhang, G. and Hodson, P. Promoting Health-Related Fitness for Elementary Students With Intellectual Disabilities Through a Specifically Designed Activity Program. Journal of Policy and Practice in Intellectual Disabilities, 2011. 8 ( 2): 77–84.

30. Subasi , F., et al., The Promotion of Physical Activity for Children with Menta retardation in TURKEY. Journal of the Brazilian Society Adapted Motor Activity, December 2007. 12(1): p. 170-174.

31. Thomas, G. R. & Kerr, M. P. Longitudinal Follow-up of Weight Change in the Context of a Community-Based Health Promotion Programme for Adults with an Intellectual Disability Journal of Applied Research in Intellectual Disabilities, 2011. 24 (4): 381–387

32. Stanish, H.I., Temple, V. A. and Frey, G. C. Health-promoting physical activity of adults with mental retardation. Mental Retardation and Developmental Disabilities Research Reviews 2006. 12(1): p. 13-21.

33. Bollard, M., Health promotion and learning disability. Nursing Standard, 2002. 16(27): p. 47-53; quiz 54. 34. Hutzler, Y. & Korsensk, O. Motivational correlates of physical activity inpersons with an

intellectual disability: a systematic literature review. Journal of Intellectual Disability Research, 2010. 54 ( 9) : 767–786.

35. Murphy, N. A. and Carbone, P. A. Promoting the Participation of Children With Disabilities in Sports, Recreation and Physical Activities Pediatrics, 2008.121; 1057- 1061.



What is Special about Special Olympics? Opportunities for Sports and Fitness for People with Intellectual Disability

Toh TH1,2, Mah LHK1,3

1 Special Olympics Asia Pacific and Special Olympics Malaysia; 2 Department of Paediatrics and Clinical Research Centre, Sibu Hospital, Sibu, Sarawak, Malaysia; 3 Oral Health Division, Sabah State Department of Health, Kota Kinabalu, Sabah, Malaysia. Email: [email protected]

Abstract Intellectual disability (ID) is a life-long condition with deficits in cognitive functioning and adaptive

skills. It affects 1 - 3% of children and adults worldwide, and the etiology is diverse. Special Olympics (SO) is the world largest sports organization for people with ID to actively engaging and competing in Olympic-type sport, and to promote understanding, acceptance and inclusion. Healthy Athletes Program® (HAP) is a global free health screenings to help SO athletes improve their health and fitness leading to enhanced well-being, quality of life and performance in sports. HAP also aims to facilitate referrals to community practitioners for additional care; and data compilation for policy development. This paper introduces the activities of the Special Olympics (SO) movement in supporting people with ID and their impacts, as well as to highlight the common health problems faced by these athletes as elicited during health screenings.

Keywords: Intellectual disability, Special Olympics, health screening sports, fitness.

Introduction

Intellectual disability (ID) is a life-long condition and it is defined as “a disability characterized by significant limitations both in intellectual functioning and in adaptive behaviour, which covers many everyday social and practical skills; and it originates before the age of 18”1. It affects 1 - 3% of children and adults worldwide2, but it can be as high as 6.5% in the developing countries3, possibly due to the effects of poverty and disadvantaged socio-demographic factors4,5. ID has diverse aetiology1, ranging from the commonest genetic causes such as Down syndrome and Fragile X1,6, to fetal alcohol syndrome7 (the commonest preventable, non-genetic cause) and autism8 (common but often undiagnosed especially in the resource-limited regions). This paper introduces the activities of the Special Olympics (SO) movement in supporting people with ID and their impacts, as well as to highlight the common health problems faced by these athletes as elicited during health screenings.

Special Olympics and the Impact

People with ID have been excluded from many aspects of society, and are less likely to be physically active9. Eunice Kennedy Shriver (1921 - 2009) believed that if given continuing opportunities, with proper instruction and encouragement, people with ID can realize their potential, develop physical fitness, demonstrate courage, as well as experience joy and friendship; and she found SO in 196810. SO is today the world largest sports organization for people with ID to actively engaging and competing in Olympic-type sport, and to promote understanding, acceptance and inclusion10,11. SO athletes of all ability levels participate through a process called “divisioning” and recognized for their performance, as the Athlete Oath says “Let me win. But if I cannot win, let me be brave in the attempt”10,11.

In 2011, the 4-yearly World Summer Games in Athens attracted more than 6,000 athletes, with an additional 4 million participating in some 53,000 competitions in 170 countries11. In early 2013, more than 3,000 SO athletes from 111 countries took part in Pyeong Chang World Winter Games in South Korea10. Through millions of these individual and worldwide acts of inclusion where people with and without intellectual disabilities are brought together, SO believes long-standing myths are dispelled, negative attitudes changed and new opportunities to embrace and celebrate people with ID are created. In addition, in response to call for



change and the movement away from the term “mental retardation”, SO have updated its terminology to “intellectual disabilities” because of the belief that language choices can and do have a powerful impact on impressions and attitudes1.

Special Olympics Healthy Athletes Program

Worldwide, people with ID experience health disparities and disparities in opportunities accessing healthcare services, placing them at high risk for morbidity and premature mortality12-15. In 1997 SO launched a global free health screenings - Healthy Athletes Program® (HAP) - to help athletes improve their health and fitness leading to enhanced well-being, quality of life and performance in sports10. In HAP, consenting athletes receive a variety of health assessments and services (Table 1) in a welcoming and fun environment by trained clinician volunteers, using standardized screening forms and procedures. Coaches and family are encouraged to join their athletes to observe the screenings, and receive information and education regarding athletes’ health that can improve performance and training compliance. The program also aims to facilitate referrals to community practitioners for additional care. Participating healthcare professionals learn about the health needs of SO athletes while volunteering their skills. Health data is compiled at each event and utilized for policy development, program development and planning, as well as public education.



Health Data from the HAP

Heath data generated from the SO HAP at the United States in 2001 has supported the belief that SO athletes have relatively poorer health status such as substantial levels of untreated caries and oral pain and related to poor oral hygiene16. At the same time, comparing to the American athletes, the international athletes from China, Lebanon, Poland, South Africa, and Turkey were more likely to have untreated caries (50.1 versus 28.2%), and less likely to have restorations (19.6 versus 62.9%), sealants (1.8 versus 13.5%), fluorosis (3.5 versus 8.8%), signs of gingival disease (27.8 versus 40.1%), or to be edentulous (0.1 versus 3.7%)17.

Table 2 shows some of the HAP results compiled from the seven SO world regions between 2007 and 2011. While there are athletes from certain regions who have higher rates of certain problems, the phenomenon is worldwide. More than 20% of SO athletes have untreated tooth decay and gingival signs in addition to 6 – 24% requiring urgent dental referral for severe pain, abscess and deep caries. In Fit Feet®, 10 – 30% of the SO athletes have bone deformation (e.g. hammertoes, brachymetarsia and bunions) and more than half have skin or nail conditions that required medical attention (e.g. infection, ingrown nails, ulcers, dry skin). On average about 15% of the athletes have eye diseases (e.g. blepharitis and amblyopia) and 30% of them needed glasses or new glasses; while nearly 20 – 35% has hearing problems. On average, more than 22% of the athletes worldwide have low bone density and nearly 40% of them were overweight or obese. There were also significant numbers of athletes who have flexibility and balance problems. These findings are discouraging, given that these athletes represented a generally better-supported and higher-functioning stratum of people with ID worldwide.

Table 3 shows data from Malaysian athletes registered with SO to-date. Comparing with the SO athletes in Asia Pacific region, Malaysian athletes seemed to be faring better with lower prevalence of eye disease, needing new glasses, pure tone hearing loss, flexibility and balance problems. During the Sarawak State Games in 2010, 31.5% (children) and 36.9% (adult) of the 138 athletes screened were considered overweight or obese, and more than 20.0% of the adult athletes were hypertensive or at risk of hypertension18. While there are many consistency and similarities, health data available can allow the local professional to address the specific issues faced by the SO athletes in Malaysia.



Other Special Olympics Initiatives

Besides sports and HAP, some of the other initiatives aiming at providing a more holistic program for the SO athletes and their families are10,11:

Healthy Communities that aims to achieve improved health outcomes by ensuring health services and reaching full potential for people with ID. It addresses some acute medical problems (e.g. malaria, tuberculosis, waterborne diseases), and conditions more prevalent in developed countries (e.g. obesity, early onset of chronic diseases).

Family Health Forum that provides families and community or professionals to interact and learn from each other regarding the needs of SO athletes in healthcare, education and inclusive activities.

Family Support Network which offers families a support system within SO. Special Olympics Young Athletes™ provides opportunity for young children with ID (2 to 7

years old) in sports training. Special Olympics Unified SportsTM brings together people with and without ID on the same

athletic team. Special Olympics Athlete Leadership Programs (ALPs) that offer athletes the opportunity

to take active leadership roles both on and off the playing field; and serving on the Boards of Directors, officiate competitions, coach other athletes and make decisions about the future of SO.

Conclusion

People with ID have a high level of health needs, which is often unmet. Through year-round sports training and athletic competition and other related programs, SO has created a model community that celebrates people’s diverse gifts. HAP is a useful screening program for population with ID, detecting unmet health needs and referring athletes to seek healthcare in the community. Health data collected can bring awareness of conditions to athletes and their family, and can be utilized to advocate health providers in improving access and provision of healthcare to people with ID.



Acknowledgement

We wish to thank the Director General of Health Malaysia for permission to publish the paper, and to Special Olympics Asia Pacific and Malaysia for the athletes’ health data. We also appreciate the expert opinions provided by the other HAP® Regional Clinical Advisors / Clinical Directors, namely Dr. Wong Chya Wei, Dr. Liaw Yun Haw and Dr. Chieng Lee Ong. We also thank Dr. Amar Singh HSS and Dr Wong See Chang for comments to improve the paper. Lastly, we thank the SO athletes and their families / coaches as well as health volunteers who have always been working well with us during the HAP.

References

1. Schalock RL, Borthwick-Duffy SA, Bradley VJ, Buntinx WHE, Coulter DL, et al. Intellectual Disability: Definition, Classification, and Systems of Supports 11th ed. Washington DC, American Association on Intellectual and Developmental Disabilities; ISBN: 978-1-935304-04-3, 2010.

2. World Health Survey. Geneva, World Health Organization, 2002–2004. Available at: http://www.who.int/healthinfo/ survey/en/. Accessed May 20, 2013.

3. Mirza I, Tareen A, Davidson LL, Rahman A. Community management of intellectualdisabilities in Pakistan: a mixed methods study. J Intellect Disabil Res; 53(6): 559-70, Jun 2009.

4. Bergen DC. Effects of poverty on cognitive function: a hidden neurologic epidemic. Neurol; 71(6):447-51, 5 Aug 2008.

5. Chapman DA, Scott KG, Stanton-Chapman TL. Public health approach to the study of mental retardation. Am J Ment Retard; 113(2):102-16, Mar 2008.

6. Gallagher A, Hallahan B. Fragile X-associated disorder: a clinical overview. J Neurol; 259(3):401-13, Mar 2012.

7. O'Leary C, Leonard H, Bourke J, D'Antoine H, Bartu A, et al. Intellectual disability: population-based estimates of the proportion attributable to maternal alcohol use disorder during pregnancy. Dev Med Child Neurol; 55(3):271-7, 2013 Mar.

8. Kim YS, Leventhal BL, Koh YJ, Fombonne E, Laska E, et al. Prevalence of autism spectrum disorders in a total population sample. Am J Psychiatry; 168(9):904-12, Sep 2011.

9. Status and Prospects: An international review of the State of Intellectual Disability Surveillance. Available at: http://www.specialolympics.org/Sections/What_We_Do/Research_Studies_ Description_Pages/Status_and_Prospects.aspx. Accessed May 20, 2013.

10. Special Olympics Movement and Healthy Athletes Program. Available at: http://www.special olympics.org and http://www.specialolympics.org/healthy_athletes.aspx. Accessed May 19, 2013.

11. Special Olympics Annual Report 2011, Special Olympics, 1133 19th Street NW Washington, DC 20036. Available at: http://www.specialolympics.org/Common/Reports.aspx. Accessed May 20, 2013.

12. Fisher K. Health disparities and mental retardation. J Nurs Scholarship. 36(1):48-53, 2004. 13. Adnams CM. Perspectives of intellectual disability in South Africa: epidemiology, policy, services for

children and adults. Curr Opin Psychiatry; 23(5):436-40, 2010 Sep. 14. Lin LP, Lin JD. Perspectives on intellectual disability in Taiwan: epidemiology, policy and services for

children and adults. Curr Opin Psychiatry; 24(5):413-8, 2011 Sep. 15. Morin D, Merineau-Cote J, Ouellette-Kuntz H, Tasse MJ, Kerr M. A comparison of the prevalence of

chronic disease among people with and without intellectual disability. Am J Intellect Dev Disabil; 117(6):455-63, 2012 Nov.

16. Reid BC, Chenette R, Macek MD. Special Olympics: the oral health status of U.S. Athletes compared with international athletes. Special Care in Dentistry; 23(6):230-3, 2003 Nov-Dec.

17. Reid BC, Chenette R, Macek MD. Prevalence and predictors of untreated caries and oral pain among Special Olympic athletes. Special Care in Dentistry; 23(4):139-42, 2003 Jul-Aug.

18. Toh TH, Nurhilda A, Chua SY, Muhamad Rais A, Islia N, et al. Body mass index, blood pressure, visual acuity and hearing status of Special Olympics Athletes in Sarawak. Int J Public Health Res (special issue): 66-71, 2011.


© Medimond . Q926C0016 65

The reliability of functional movement screen tm ( fms tm ) in the healthy young men

Maeda N.1, Urabe Y.1, Fujii E.1, Shinohara H.1, Sasadai J.1, Moriyama N.1, Kotoshiba S.1, Yamamoto T.1

1 Hiroshima University, (Japan) e-mail:[email protected]

Abstract

FMSTM is a screening instrument which evaluates selective fundamental movement patterns to determine potential injury risk. FMSTM system has been validated. However its intrarater and interrater reliability between groups of medical staff with varying amounts of experience to determine if clinical experience and previous experience using FMSTM has not been reported. This study aimed to examine intrarater test–retest and interrater reliability of the Functional Movement ScreenTM (FMSTM) test battery. Subjects were 12 healthy men. FMSTM scores were evaluated by 2 physical therapists, and interrater, intersession, and intrasession reliability was calculated. FMSTM is designed so that the 7 fundamental movement patterns are considered together as a comprehensive cross section of functional movement. These 7 tests, used to assess overall functional movement ability, include the deep squat, the hurdle step, the in-line lunge, the shoulder mobility, the active straight leg raise, the trunk stability push-up, and the rotary stability. Intrarater intraclass correlation coefficient was 0.95; kappa coefficient was moderate for all movements except in-line lunge for the right side and rotary stability. FMSTM scores displayed high intersession and interrater reliability. With the exception of in-line lunge and rotary stability, all tasks displayed moderate-to-high intersession reliability and good-to-high interrater reliability for healthy men. Future studies need to be performed using clinical outcomes to confirm the effectiveness of the screening tool a function to predict the risk of personal injury physically active individuals.

Keywords: Functional Movement ScreenTM, reliability, healthy men, Physical Therapist

Introduction

The risk of musculoskeletal injury is a concern in physical training. Predisposing factors for injury include age, gender, injury history, body size, local anatomy and biomechanics, aerobic fitness, muscle strength, imbalance, tightness, ligamentous laxity, central motor control, psychological and psychosocial factors, as well as general mental ability[1] [2]. To prevent traumatic injuries, it is necessary not only to understand their etiology and underlying mechanisms but also to develop means for early detection of the above-mentioned predisposing factors.

However, in many medical centers, screening of athletes and non-athletes is still based on personal experience, subjective observations, and mental evaluations. In fact, initially, few standardized assessment devices and evaluation indexes for posture and movement patterns existed. More recently, screening has shifted towards a more functional approach based on the assumption that identifiable biomechanical deficits in fundamental movement patterns have the potential to limit performance and render the athlete susceptible to injury[3]. This type of screening requires the rater to have experience in observation and good knowledge of functional anatomy and kinematics.

Recently, Cook et al. [4] [5] have developed the Functional Movement ScreenTM ( FMSTM ) of a tool to assess fundamental movement skills. The tool consists of 7 functional movements that assess flexibility, neuromuscular coordination, trunk and core strength and stability, asymmetry in movement, acceleration, deceleration, and dynamic flexibility [6].

The FMSTM system has been validated, however its intrarater and interrater reliability between groups of physical therapists with varying amounts of experience to determine if clinical experience and previous experience using the FMSTM has not been reported [4] [5]. Therefore, this study aimed to examine intrarater test–retest and interrater reliability of FMSTM demonstrated among physical therapists for healthy volunteer men students.



Material and Methods

1.1. Participants

Twelve volunteers (10 men: mean age 21.7 ± 3.3 years, mean height 168.3 ± 4.9 cm, mean weight 61.1 ± 6.7 kg, BMI 20.6 ± 4.3) participated in this study. Healthy individuals were defined as those with no incidence of upper or lower extremity injuries within the last 6 months that had resulted in 2 or 3 days of incapacity and those with no orthopaedic surgery in the past year. The study protocol was approved by the Ethics Committee of the Graduate School of Health Sciences, Hiroshima University (#1239).

1.2. Methods

The rater participating in this study consisted of 2 physical therapists with more than 4 years’ experience. The primary rater for the intersession reliability was a credentialed performance specialist with FMSTM Certified expert. Novice individuals were defined as having taken the standardized introductory training by an expert and have used the FMSTM more than a year. The secondary rater read the FMSTM manual before scoring the FMSTM and had scored the FMSTM during some type of testing trial for healthy person and athletes. Two physical therapists were randomly assigned to the participants to assess intrarater test-retest reliability by assessing the FMSTM on day 1 and day 2. The subjects arrived at the University’s Sports Rehabilitation Research Laboratory wearing athletic clothing. The subjects were tested on 2 days, separated by 1 week. On both days, the subjects performed the FMSTM test. One week later, the subjects retested to the Sports Laboratory, and each subject performed the same assessments in the same order.

The FMSTM is designed so that the 7 fundamental movement patterns are considered together as a comprehensive cross section of functional movement. These 7 tests, used to assess overall functional movement ability, include the deep squat (DS), the hurdle step (HS), the in-line lunge (IL), the shoulder mobility (SM), the active straight leg raise (ASLR), the trunk stability push-up (TSP), and the rotary stability (RS) (Cook et al., 2006a; 2006b). There are 3 clearing tests, each associated with one of the individual FMSTM tests, which check for pain accompanying shoulder internal rotation/flexion and end-range spinal flexion and extension pain. The FMSTM is scored on a 0-3 ordinal scale. A score of 3 represents the subject’s ability to perform the functional movement pattern as described, a score of 2 indicates that some type of compensation is present when completing the pattern, and a score of 1 is given when the subject is unable to perform the movement pattern. A zero is recorded if there is pain associated with any portion of the test including the clearing tests. The lowest score from the three trials was used for scoring. From 7 movements, a composite score was calculated out of a potential 21 points, with higher scores indicating the greatest function.

The difference in mean values between the total FMSTM score measured by rater 1 was used the paired t-test [4] [5]. Test-retest reliability for the FMSTM item scores and total score was determined by using an ICC1,1. The ICC1,1 was used to determine the reliability of the intersession scoring of the FMSTM and the intrasession interrater scoring of the FMSTM. The researchers interpreted the ICC reliability according to the following criteria: high reliability, 0.90–0.99; good reliability, 0.80–0.89; fair reliability, 0.70–0.79; poor reliability, 0.00–0.69 [7]. Intersession reliability and interrater reliability for the FMSTM item scores (DS, HS, IL, SM, ASLR, TSP, and RS) was determined by using a weighted Cohen’s kappa (kappa) used for categorical data. The interpretations of the weighted kappa were based on Landis and Koch[8]: Excellent reliability, 0.81–1.0; good reliability, 0.61–0.80; moderate reliability, 0.41–60; fair reliability, 0.21–0.40; poor reliability, <0.20.

1.2. Statistical analysis

Statistical significance was set a priori at p<0.05. Statistical analysis was performed using the Statistical Package for the Social Sciences ver. 20.0J for Windows the SPSS ® statistical package (SPSS Inc., Chicago, IL, USA) for Windows ®.

Results

For the intrarater reliability of Rater 1, the ICC (95%CI) was 0.95 (0.94-0.97) for the FMSTM i total score. The mean for total FMSTM score of 1 day for subjects was 16.6 ± 1.6 and for the score of 2 day was 16.6 ± 1.6. The difference in mean values between the total FMSTM score was no significant (Table 1).

The tests were analyzed by addressing the kappa values of both individual right and left sides for each of the 7 tests. The inter-rater reliability (kappa) for each score of the individuals’ right and left side performance and for the final score for each test is presented in Table 2.



Tab 1. Intra-ratar reliability in overall FMSTM

FMSTM

Minimum Maximum 95%CI ICC1.1

1day FMSTM

16.5 ± 1.5 14 19

2day FMSTM

16.6 ± 1.5 14 19 0.94-0.97 0.95

Mean±Standard Diviation，ICC = Intraclass crrelation coefficient

Tab 2. Kappa values as determined by comparing the pair of the raters

FMSTM

items Agreement (%) Kappa Agreement Level

Deep Squat 90 0.61 good

Hurdle Step (Rt) 90 0.79 good

Hurdle Step (Lt) 100 1.00 excellent

In-line Lunge (Rt) 80 0.55 moderate

In-line Lunge (Lt) 100 1.00 excellent

Shoulder Mobility (Rt) 90 0.61 good

Shoulder Mobility (Lt) 100 1.00 excellent

Active Straight Leg raise (Rt) 100 1.00 excellent

Active Straight Leg raise (Lt) 90 0.83 excellent

Trunk Stability push up 90 0.63 good

Rotary Stability (Rt) 100 1.00 excellent

Rotary Stability (Lt) 80 0.63 moderate

The pair of raters demonstrated excellent agreement on 6 of the 12 test components, including HS (Lt),

SM (Lt), ASLR (Both), and RS (Rt). Good agreement was evident on 4 of the 12 test components including DS, HS (Rt), SM (Rt), and TSP. IL (Rt) and RS (Lt) demonstrated moderate agreement. The remaining scores demonstrated good agreement between two raters.

Discussions

Fundamental movements, such as those tested in FMSTM, operate as the basis of more complex movement patterns used in common daily activities and sports. The results of our interrater reliability for FMSTM total score are similar with those previously reported by Onate et al. [9]. The mean composite score reported in this study is slightly lower than that reported for a group of professional male football players (16.9 points) [10]. It might be expected that professional football players score better than the average athlete due to their intensive training regimens.

In this study, we showed that FMSTM is a fundamental movement-screening tool with moderate-to-high intersession reliability and good-to-high interrater reliability for healthy young men. Hence, physical therapists and other health professionals may use FMSTM as a training system for preventing injuries and improving physical performance of athletes and non-athletes. For intrarater reliability of Raters 1, ICC was 0.95, indicating high reliability in all cases. In previous studies, Currier [11] stated that 0.90–0.99 = high reliability, 0.80–0.89 = good reliability, 0.70–0.79 = fair reliability, and <0.69 = bad reliability. Chinn [12] reported that a device was useful if the ICC was > 0.6. Based on these studies, this study can suggest that the FMSTM is reliable and useful for applications. The results supported hypothesis of this study. A preliminary study by Minick et al. [13] found acceptable levels of interrater agreement on FMSTM component scores among novice and expert raters in a sample of active college-age participants using videotape review. However, in this study, interrater agreement was only calculated for individual FMSTM component scores and not for the overall FMSTM composite score; moreover, test–retest reliability was not assessed. In another study, Gribble et al. [14] reported that FMSTM demonstrated moderate-to-strong intrarater reliability among clinicians but not among students preparing to be athletic trainers. It appears that an experienced physical therapist can contribute to the reliability of FMSTM across testing sessions. However, Teyhen et al. [15] reported moderate-to-good interrater and intrarater



reliability among novice raters too. Therefore, experience in observation may not be the only factor influencing interrater and intersession reliability.

The FMSTM can be performed with good intersession and interrater reliability for each task of the system, with caution warranted for IL and RS component. In our study, IL and RS task yielded the lowest kappa value for intrasession interrater reliability. Minick et al. [13] reported that DS and IL yielded substantial to moderate reliability in both intersession and interrater reliability assessments. Similary, Schneiders et al. [3] reported that IL yielded substantial reliability in interrater reliability assessments. A possible explanation for this low reliability is that IL and RS are dynamic movements, with both hip and knee joints being simultaneously assessed in a closed kinetic chain [10]. Furthermore, the rater’s observation location could have played a key role in the poor interrater reliability of IL and RS. Onate et al. [9] indicatede the real-time assessment of the simultaneous 3-dimensional assessment of hip flexion and external rotation, the raters positioning when assessing this test is quite important. A limitation of this study was the relatively small sample size and the inclusion of young men participants alone. Therefore, generalization of our findings to the general population is not possible without further investigation. However, despite these limitations, the FMSTM remains a reliable measurement tool for functional movement analysis.

In conclusion, FMSTM is a highly reliable test battery for functional movement analysis demonstrated among physical therapists in healthy young men. Further studies are necessary to measure the reliability of FMSTM scores in women and athletes. Future studies need to be performed using clinical outcomes to confirm the effectiveness of the screening tool a function to predict the risk of personal injury physically active individuals.

References

[1] Taimela S, Kujala UM, Osterman K. (1990). Intrinsic risk factors and athletic injuries. Sports Med 9(4), pp. 205-215.

[2] Devan MR, Pescatello LS, Faghri P, Anderson J. (2004). A prospective study of overuse knee injuries among female athletes with muscle imbalances and structural abnormalities. J Athletic Training 39(3), pp. 263-267.

[3] Schneiders AG, Davidsson A, Hörman E, Sullivan SJ. (2011). Functional movement screen normative values in a young, active population. Int J Sports Phys Ther 6(2), pp. 75-82.

[4] Cook G, Burton L, Hoogenboom B. (2006). Pre-participation screening: The use of fundamental movements as an assessment of function - Part 1. N Am J Sports Phys Ther 1(2), pp. 62-72.

[5] Cook G, Burton L, Hoogenboom B. (2006). Pre-participation screening: The use of fundamental movements as an assessment of function - Part 2. N Am J Sports Phys Ther 1(3), pp.132-139.

[6] Pollock ML, Gaesser GA, Butcher JD, Despres JP, Dishman RK, Franklin BA, Garber CE. (1998). The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness and flexibility in health adults. Medicine and Science in Sports and Exercise 30(6), pp. 975-991.

[7] McGuine TA, Greene JJ, Best T, Leverson G. (2000). Balance as a predictor of ankle injuries in high school basketball players. Clin J Sport Med 10(4), pp. 239–244.

[8] Landis JR, Koch GG. (1977). The measurement of observer agreement for categorical data. Biomechanics 33(1), pp. 159–174.

[9] Onate JA, Dewey T, Kollock RO, ThomasKS, Van Lunen BL, DeMaio M, Rinqleb SI. (2012). Real-time intersession and interrater reliability of the functional movement screen. J Strength Cond Res 26(2), pp. 408-415.

[10] Kiesel K, Plisky PJ, Voight ML. (2007). Can serious injury in professional football be predicted by a Preseason Functional Movement Screen? N Am J Sports Phys Ther 2(3), pp.147-158.

[11] Currier DP. (1990). Elements of research in physical therapy. Third ed. Baltimore: Williams and Wilkins, pp. 167.

[12] Chinn S. (1991). Repeatability and method comparison.Thorax 46(1), pp. 454–456. [13] Minick KI, Kiesel KB, Burton L, Taylor A, Plisky P, Butler RJ. (2010). Interrater reliability of the

functional movement screen. J Strength Cond Res 24(1), pp. 479-486. [14] Gribble P, Brigle J, Pietrosimone B, Pfile KR, Webster KA. (2010). Intrarater reliability of the Functional

Movement ScreenTM. J Strength Cond Res 24(2), pp. 479-486. [15] Teyhen DS, Shaffer SW, Lorenson CL, Halfpap JP, Donofry DF, Walker MJ, Dugan JL, Childs JD.

(2012). The Functional Movement Screen: a reliability study. J Orthop Sports Phys Ther 42(6), pp. 530-540.



The Effects of Changes in Rules and Regulations on Sepaktakraw Match Performance

Nagahama H.1, Kubo Y.2, and Sasaki S.2

1 Asia University, (Japan) 2 Tokyo Ariake University of Medical and Health Sciences, (Japan) e-mail: [email protected]

Abstract

The aim of this study was to investigate the effects of changes in rules and regulations on match performance in sepaktakraw. Data sources were ten matches in the 16th Asian Games in 2010 (old rules) and eight matches in the 27th King’s Cup World Championship in 2012 (new rules). For the purpose of data collection, one digital movie camera was placed at the backside of the court and used to record all the players’ actions and ball movements for the entirety of the matches. The collected data were later transferred to DVDs and the temporal characteristics of matches were identified. Also, the success and failure rates of the specific skills during the matches were analyzed. The mean duration of matches operated on the old rules was 44.0 ± 13.0 min. It was 47.6 ± 14.4 min for Regu events (best-of-five sets) and was 29.5 ± 4.5 min for Team events (best-of-three sets) operated on the new rules. Due to rule changes, the average success rate of serves significantly increased from 33.1 to 41.7% for winning teams (p < 0.05); however, this rate did not change statistically for losing teams. The average failure rate of serves of winning teams did not change significantly; however, this rate significantly increased from 16.3 to 27.2% for losing teams (p < 0.01). This study describes how the change in rules and regulations affects match performance, especially the serving events, in sepaktakraw.

Keywords: Sepaktakraw, notational analysis, change in rules and regulations, match performance

Introduction

Sepaktakraw, whose origin is said to date back to the 9th century, is a popular sport in Southeast Asia. Official rules and regulations have been developed internationally in recent decades. Competitive players are required complex ball skills (kicking and juggling), agility, and the ability to perform acrobatic movements on a court similar in size to that of a badminton court during a match. The team consists of three players and is performed like volleyball, except that use of hands and arms is not permitted. A competitive sepaktakraw game is characterized by the integration of five skills: serving, reception, setting, attacking, and blocking.

Sports sciences have contributed greatly to the development of modern sports such as soccer, tennis, volleyball, etc. Breakthroughs in computer technology in recent years have contributed to advancing dramatically notational match analysis. However, sepaktakraw lacks worldwide popularity; therefore, scientific evidence regarding this sport has been limited (Aziz et al., 2003, Jawis et al., 2005, Joseph et al., 2009, Nagahama, 2011, Sujae and Koh, 2008).

The International Sepaktakraw Federation (ISTAF), established in 1992, has implemented changes in rules and regulations several times in the past. In 2011, ISTAF amended the rules and regulations and official tournaments authorized by ISTAF have been operated on the basis of the new rules. The main changes were the scoring system stipulation that each set is won by the side which scores from 21 to 15 points and the serving system stipulation that service alternates every three points regardless of which side wins a point. The aim of this study was to investigate the effects of changes in rules and regulations on match performance in sepaktakraw. We hypothesized that serving events may affect the outcome of a match more than ever due to rule changes.



Method

Data Source, Collection, and Analysis

Ten matches in the 16th Asian Games of China 2010 were chosen for analysis. This tournament was carried out using the old rules and regulations, and four national teams (Thailand, Malaysia, Myanmar, and China) for Men’s Regu events and two national teams (Thailand and Malaysia) for Men’s Team events were selected. Furthermore, eight matches in the 27th King’s Cup World Championship of Thailand 2012 were also chosen for analysis. This tournament was carried out using the new rules and regulations, and four national teams (Japan, Korea, Indonesia, and Philippine) for Men’s Regu events and two national teams (Thailand and Korea) for Men’s Team events were selected. For the purpose of data collection, one digital movie camera (HDR-CX370V, SONY, Tokyo, Japan) was placed at the backside of the court and recorded all the players’ actions and ball movements for the entirety of the matches. The collected data were later transferred to DVDs and the matches’ temporal characteristics were identified with a stopwatch. Also the success and failure rates of the specific skills (i.e. serving and reception) during the matches were analysed. To ensure accuracy, all matches were observed by one operator who was familiar with this analysis.

Notational Analysis

A notational analysis system was developed to modify the 2008 volleyball statisticians’ manual created by the National Collegiate Athletics Association (NCAA, 2008). Serving and reception were selected from among the specific skills because these would be affected by the new rules and regulations. Each of the skills’ definitions and assessment criteria are listed below:

Serve--- A serve is when a player attempts to kick the ball over the net into the opponent’s court. There are four possible outcomes for every served ball:

(1) A service ace (SA) is a serve that results directly in a point. A SA is awarded (a) if the serve strikes the opponent’s court untouched; (b) if the serve is passed by the opponent but cannot be kept in play; or (c) if the referee calls a fault on the receiver (e.g., ball contact with hands or arms).

(2) A service error (SE) is charged (a) if the serve fails to go over the net and lands on the side of the team serving; (b) if the serve is out of bounds; or (c) if the server foot-faults.

(3) A service effectiveness (SEF) is awarded if the serve is received by the opponent but this act creates an unfavorable situation (e.g. the ball cannot be raised easily by a setter).

(4) A zero serve (ZS) occurs when a serve does not result in a SA, SE, or SEF, but play continues. The success and failure rates of serves are expressed as follows:

success rate total SA total SEF

total attempts failure rate total SE

total attempts

Reception--- A reception is when a player attempts to pass a served ball to a teammate. There are two possible outcomes when a player attempts to pass a served ball:

(1) A reception success (RS) is awarded if the player continues play by successfully passing a served ball.

(2) A reception error (RE) is charged (a) if the serve strikes the floor; (b) if the player passes the ball but it cannot be kept in play; or (c) if the referee calls a fault (e.g., ball contact with hands or arms).

The success and failure rates of reception are expressed as follows:

success rate total RS

total attempts failure rate total RE

total attempts

Statistics

A student’s t-test was used to compare the temporal characteristics and the success and failure rates of the specific skills between the old and new rules and regulations. All statistical analyses were performed using a software package of Statcel 3 (OMS Publishing Inc., Saitama, Japan). A significance level of p < 0.05 was used for all analyses and data are presented as mean ± SD.

Results

The duration of a rally was defined as the time from when the ball was thrown by the thrower until the ball was “dead.” The duration of a recovery was defined as the time between rallies. The duration of a set was defined as the time from when the first rally starts to when the final rally terminates, including official breaks (e.g. substitution, and injury) but excluding timeouts. And the duration of a match is defined as the sum of all sets’ durations. Mean duration of matches for Regu and Team events (best-of-three sets) operated on the old



rules was 44.0 ± 13.0 min. It was 47.6 ± 14.4 min for Regu events (best-of-five sets) and 29.5 ± 4.5 min for Team events (best-of-three sets) operated on the new rules. Other temporal characteristics of sepaktakraw match are presented in Tab.1.

Tab. 1. Duration of a rally, a recovery, and a regular set of sepaktakraw matches operated on the old and the new rules and regulations.

Old rules New rules

Rally duration (s): 4.98 ± 2.52 (1.40 - 21.67) 4.70 ± 2.48 (1.53 - 17.20)

Recovery duration (s): 28.2 ± 9.1 (9.1 - 75.0) 28.6 ± 7.9 (5.9 - 85.6)

Regular set duration (min : s): 19:31 ± 4:23 (12:58 - 28:06) 13:36 ± 2:42*** (9:07 - 18:10)

Values are mean ± SD and (range). *** p < 0.001.

The success and failure rates of serves and receptions associated with the rule changes are presented in

Fig. 1. Due to rule changes, the average success rate of serves significantly increased from 33.1 ± 6.8 to 41.7 ± 7.3% for winning teams (p < 0.05); however, this rate did not change statistically for losing teams (23.8 ± 8.1 and 26.8 ± 10.0%, respectively). The average failure rate of serves of winning teams did not change significantly (17.0 ± 7.4 and 17.3 ± 7.8%, respectively); however, this rate significantly increased from 16.3 ± 5.2 to 27.2 ± 7.2% for losing teams (p < 0.01). Moreover, the average success rate of receptions significantly decreased from 60.3 ± 8.2 to 49.3 ± 8.5% for losing teams (p < 0.05); however, this rate did not change statistically for winning teams (71.8 ± 8.5 and 63.0 ± 14.6%, respectively). The average failure rate of receptions of winning teams did not change significantly (28.2 ± 8.5 and 37.0 ± 14.6%, respectively); however, this rate significantly increased from 39.7 ± 8.2 to 50.7 ± 8.5% for losing teams (p < 0.05).

Fig. 1. Success and failure rates of serves (a) and receptions (b) associated with the rule changes. Values are mean ± SD. * p < 0.05, ** p < 0.01.

Discussion

Rules and regulations and match performance are closely associated with each other, therefore we should be more cautious if amendment is required. ISTAF has implemented changes in rules and regulations several times in the past. In the revision of 1999, the main change was the serving system that was used from “side by side” to “rally point.” And in 2011, ISTAF instituted further amendments. The main changes were the scoring system stipulating that each set is won by the side which scores from 21 to 15 points and the serving system stipulating that service alternates every three points, regardless of which side wins a point. We investigated the effect on the temporal characteristics and the success and failure rates of the serving events (i.e.



serving and reception) during the match with the change in rules and regulations revised in 2011. Our findings demonstrated that the change in rules did not affect the duration of a rally or recovery; however, the duration of a set was significantly shortened, suggesting that the progression of the match is faster (Tab.1). Sepaktakraw players are not required to have high aerobic capacity (Asiz et al., 2003) and the duration of a rally is approximately 5 s during a match (Asiz et al., 2003, Nagahama, 2011). For the more explosive actions (i.e. serving, attacking, blocking, etc.) that appear frequently in a match, shorter duration of a set may reduce physiological stress. On the other hand, the number of points required to win one set was changed from 21 to 15 points, increasing the importance of a single point in a game. The server performs aggressively to score first from the beginning of a match; however, a service error directly advances the score in the opposing team. Therefore, the server may suffer greater psychological stress than ever during a match. In this regard, we must clarify the interviews with servers in the future.

Our findings also demonstrated that due to rule changes, the skill of the server would affect the outcome of a match more than ever. The rule change to continue the serve three times continuously suggested the possibility that the winning team could proceed with an advantage. On the other hand, in order to from a disadvantaged position, the losing team must serve more aggressively to obtain a service ace or a reception error; these tactics would cause a significant increase in the failure rate of serves for the losing team. Furthermore, it is necessary not only to increase service aces and serve effectiveness and to decrease services errors, but also to decrease zero serves that could be attacked easily by the opposition (Fig.1). Because continuous rallies are limited in a match, if a reception succeeds, the score tends to be determined by the next play, in many cases an attack (Nagahama, 2011). Serving and reception are closely linked; therefore, an exact serve with a change in speed would induce a reception error. On the other hand, if the ability to receive could be enhanced, an attack after a reception increases the probability of gaining the point (Nagahama, 2011). As a result, it would be possible to proceed with an advantage in this situation. In particular, due to rule changes, reception performance decreased only for losing teams (Fig. 1). These results suggest that to strengthen the ability of a reception is urgently needed.

Notational analysis has been one of the effective methods for analyzing sports. This method is especially utilized in competitions classified as net sports, such as volleyball (Han and Robert, 1992, Patsiaouras et al., 2011), tennis (O’Donoghue and Ingram, 2001), and table tennis (Malagoli et al., 2013). The papers cited here presented characteristics of these sports such as temporal data, playing style, rates of success and failure, etc.; however, this information has been limited in the sepaktakraw research (Aziz et al., 2003, Nagahama 2011). This study to analyze the rates of success and failure of specific skills represents the first notational analysis of sepaktakraw competition (Fig.2); therefore, it will contribute to clarifying the scientific characteristics of sepaktakraw.

In summary, our findings expand on the limited data in the previous literature regarding sepaktakraw. We are able to demonstrate that new notational analysis can be utilized on research in this sport. The obtained information will provide both coaches and players practical ideas for winning strategy.

References

[1] Aziz, AR., Teo, E., Tan, B., and Chuan, TK. (2003). Sepaktakraw: A descriptive analysis of heart rate and blood lactate response and physiological profiles of elite players. International Journal of Sports Science 15, 1-10.

[2] Han, JE., and Robert, WS. (1992). Statistical analyses of volleyball team performance. Research Quarterly for Exercise and Sport 63, 11-18.

[3] Jawis, MN., Singh, R., Singh, HJ., and Yassin, MN. (2005). Anthropometric and physiological profiles of sepaktakraw players. British Journal of Sports Medicine 39, 825-29.

[4] Malagoli, LI., Di, MR., and Merni, F. (2013). A notational analysis of shot characteristics in top-level table tennis players. European Journal of Sports Science, http://dx.doi.org/10.1080/17461391.2013. 819382

[5] Nagahama, H. (2011). Scientific analysis in sepaktakraw. Journal of the society for general academic and cultural research 18, 109-27. (In Japanese with English abstract)

[6] National Collegiate Athletic Association (NCAA). (2008). Volleyball statisticians’ manual. [7] O' Donoghue, P., and Ingram, B. (2001). A notational analysis of elite tennis strategy. Journal of Sports

Sciences.19, 107-15. [8] Patsiaouras, A., Moustakidis, A., Charitonidis, K., and Kokaridas, D. (2011). Technical skills leading in

winning or losing volleyball matches during Beijing Olympic Games. Journal of Physical Education and Sport 11, 149-152.

[9] Sujae, IH., and Koh, M. (2008). Technique analysis of the kuda and sila serves in sepaktakraw. Sports Biomechanics 7, 72-87.



Resitance exercise with blood flow restriction in

women

Okita K., Takada S., Suga T., Kadoguchi T., Taniura T., Morita N., Yokota T.,

Kinugawa S., Tsutsui H.

Department of Sport Education, Hokusho University

Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine

Research Fellow of the Japan Society for the Promotion of Science

Hokkaido University of Education, Iwamizawa

Summary

Resistance exercise with blood flow restriction is a new training method providing significant training

effects despite the use of low-intensity loads. We compared training effects of resistance exercise with BFR

between men and women. Training effects were similarly enhanced by BFR during low-intensity resistance

exercise in men and women, however, those did not reach the levels in high-intensity. Optimal training stimulus

in exercise with BFR could be achieved by increasing mechanical intensity to 30%1-RM or greater.

Keywords: muscle metabolism; ischemia; sex difference; training; muscle hypertrophy

Introduction

Skeletal muscle bulk is becoming an important therapeutic target in medicine1,2. In order to increase

muscle mass, however, intensive mechanical stress must be applied to the muscles, and such stress is often

accompanied by orthopedic and cardiovascular problems3. Resistance exercise with blood flow restriction (BFR)

is a new training method providing significant training effects despite the use of low-intensity loads4,5. We

observed that BFR remarkably enhanced muscular metabolic stress in resistance exercise, although there was a

wide range of individual differences in the responses6-8. It is possible that the diversity could be caused by

gender difference in muscular characteristics. Previously, we demonstrated that training effects such as strength

gain and muscle hypertrophy closely related to intramuscular metabolic stress during exercise9. Therefore, we

compared intramuscular metabolic stress during resistance exercise with BFR between men and women.



Materials and Methods

Twenty-six age-matched men (n=13, 224 yrs) and women (n=13, 214 yrs) were recruited and

performed unilateral plantar-flexion (30 repetitions/min for 2 min). The exercise protocols were as follows:

low-intensity exercise (L) with 20% of one repetition maximum (1-RM), L with BFR, and high-intensity of 65%

1-RM without BFR (H). BFR was applied by 130% of the subject’s resting blood pressure. We added the

protocols of 30, 40% 1-RM with BFR to determine an optimal protocol. Muscular metabolic stress, defined as

phosphocreatine and intramuscular pH decrease were evaluated by using 31P-magnetic resonance spectroscopy

(details in the previous studies6-9).

Results

Phosphocreatine decreases were statistically similar between men and women in all protocols (Fig 1).

Intramuscular pH decreases showed similar trend. Compared with L, metabolic stresses were enhanced similarly

by BFR in men and women, while those did not reach the levels in H (Fig 1). By increasing intensity to greater

than 30% 1-RM, the metabolic stresses reached to those in H (Fig 2).

Conclusions

Effects of resistance exercise with BFR on muscular stress might be similar in men and women.

Optimal muscular stress in BFR exercise could be achieved by increasing mechanical intensity to 30%1-RM or

greater.

Acknowledgements

This study was supported, in part, by Grant-in-Aid for Scientific Research from Japan Society for the

Promotion of Science, KAKENHI (23500784), Hokusho University Northern Regions Lifelong Sports Research

Center (SPOR) and The Descente and Ishimoto Memorial Foundation for The Promotion of Sports Science.



References

1) Braith RW, Stewart KJ. Resistance exercise training: its role in the prevention of cardiovascular disease.

Circulation, 2006;113:2642-50.

2) Hülsmann M, Quittan M, Berger R, Crevenna R, Springer C, Nuhr M, Mörtl D, Moser P, Pacher R.

Muscle strength as a predictor of long-term survival in severe congestive heart failure. Eur J Heart Fail.

2004;6:101-7.

3) Kraemer WJ, Ratamess NA. Fundamentals of resistance training: progression and exercise prescription.

Med Sci Sports Exerc, 2004;36:674-88.

4) Takarada Y, Takazawa H, Sato Y, Takebayashi S, Tanaka Y, Ishii N. Effect of resistance exercise combined

with moderate vascular occlusion on muscular function in human. J Appl Physiol, 2008;88:2097-2106.

5) Abe T, Yasuda T, Midorikawa T. Skeletal muscle size and circulating IGF-1 are increased after two weeks

of twice daily KAATSU resistance training. Int J KAATSU Training Res. 2008;1:6-12.

6) Okita K. Effects of Blood Flow Restriction on Intramuscular Energetic Metabolism During Resistance

Exercise. Adv. Exerc. Sports Physiol. 2010;15:121-25.

7) Suga T, Okita K, Morita N, Yokota T, Hirabayashi K, Horiuchi M, Takada S, Takahashi T, Omokawa M,

Kinugawa S, Tsutsui H. Intramuscular Metabolism during Low-Intensity Resistance Exercise with Blood

Flow Restriction. J Appl Physiol. 2009;106:1119-24.

8) Takada S, Okita K, Suga T, Omokawa M, Kadoguchi T, Sato T, Takahashi M, Yokota T, Hirabayashi K,

Morita N, Horiuchi M, Kinugawa S, Tsutsui H. Low-intensity exercise can increase muscle mass and

strength proportionally to enhanced metabolic stress under ischemic conditions. J Appl Physiol.

2012;113:199-205.

9) Takada S, Okita K, Suga T, Omokawa M, Morita N, Horiuchi M, Kadoguchi T, Takahashi M, Hirabayashi

K, Yokota T, Kinugawa S, Tsutsui H. Blood Flow Restriction Exercise in Sprinters and Endurance

Runners. Med Sci Sports Exerc. 2012;44:413-9.



Ultrasonographic measurement of the posterior ankle region at various plantar flexion angles

Sasadai J.1, Urabe Y.1, Maeda N.1, Fujii E.1, Shinohara H.1

1 Graduate School of Biomedical and Health Sciences, Hiroshima University (Japan) e-mail:[email protected]

Abstract

Posterior ankle impingement syndrome (PAIS), a common disorder in soccer players and ballet dancers, is characterized by posterior ankle pain with excessive plantar flexion. Soft tissue, bony processes, unfused ossicles, or osseous fragments trapped between the posterior tibial plafond and superior calcaneus lead to symptoms. However, whether such impingement occurs at higher than normal plantar flexion angles, as occurs in soccer kicks and the pointe position in ballet, is not known. This study aimed to determine, from ultrasonographic measurements, whether the distance between the tibia and calcaneus decreases as ankle plantar flexion angle increases. Such knowledge could help explain the mechanism by which excessive ankle plantar flexion causes PAIS.

Sixteen healthy volunteers (8 men, 8 women) with no history of foot or ankle injury consented to participate. Posterior ankle images were captured using an LOGIQ e Expert ultrasound device at 7 dorsal/planter flexion angles determined by a goniometer. Distance between the posterior tibial plafond and superior calcaneus was measured on the sagittal plane using the inbuilt ultrasound analysis software. One-way ANOVA was used to compare the distance in the 7 angle conditions. When interactions were detected, further analysis was carried out using Scheffe’s test. P<0.05 was considered significant. All data analysis was performed using Statcel 2.

Distance between the posterior tibial plafond and superior calcaneus decreased as ankle plantar flexion angle increased (men: 53.4±4.4 to 22.8±2.7 mm, women: 50.6±2.4 to 22.5±2.5 mm). Significant shortening was apparent between maximal dorsal flexion and 30° plantar flexion (p<0.05), but not at 45° plantar flexion or maximal plantar flexion. The distance may not have shortened further after 30° plantar flexion because certain contact or impingement could have already occurred in the ankle posterior region.

Keywords: posterior ankle impingement syndrome, ultrasonography, ankle plantar flexion

Introduction

Posterior ankle impingement syndrome (PAIS), such as os trigonum syndrome, is a common sports injury in soccer players and ballet dancers [1] [2]. PAIS is characterized by posterior ankle pain with forceful ankle plantar flexion. Soft tissues, bony processes, unfused ossicles, or osseous fragments entrapped between the posterior tibial plafond and the superior calcaneus lead to symptoms [1] [3].

However, our recent study showed that the angle of maximal ankle plantar flexion on ball impact does not exceed that of passive maximal plantar flexion [4]. In addition, whether such impingement occurs at higher than normal plantar flexion angles, as occurs in soccer kicks and the pointe position in ballet, is not known.

Ultrasonography is often used in the diagnosis of the musculoskeletal disease as quick, cheap and widespread way [5]. Some studies had ultrasonographically observed sign of PAIS, such as thickening of the joint capsule and triangular bone in posterior ankle region [3] [6]. However, to our knowledge, there have been no published studies up to date that have observed change in the position relationship between tibia and calcaneus.

The purpose of this study was to determine, from ultrasonographic measurements, whether the distance between the tibia and calcaneus decreases as ankle plantar flexion angle increases. Such knowledge could help explain the mechanism by which excessive ankle plantar flexion causes PAIS. We hypothesised if the ankle plantar flexion angle increases, the distance between the tibia and calcaneus is shorten.

Material and Methods



1.1. Participants

Sixteen healthy volunteers (8 men: mean age 23.0 ± 3.7 years, mean height 169.1 ± 3.7 cm, mean weight 62.0 ± 4.8 kg, mean BMI 21.7 ± 1.9 ; 8 women: mean age 23.0 ± 1.5 years, mean height 161.0 ± 5.1 cm, mean weight 53.1 ± 5.8 kg, mean BMI 20.5 ± 1.8) participated in this study. Participants were defined as those with no history of foot or ankle injury. The study protocol was approved by the Ethics Committee of the Graduate School of Health Sciences, Hiroshima University (ID: 1231).

1.2. Methods

The participants were seated on a chair. A transparent glass water tank (600*300*360 mm, EJ-60, EHEIM, Japan) was used in order to capture clear ultrasonographic image, because it was difficult to capture complex posterior ankle region in a common method using echo gel. The tank was filled with water. Water temperature was controlled at 35°C, which is insensitive temperature. During the measurement, participants were instructed to put their leg into the water tank without loading a lot. Both legs were measured. The sequencing of right and left was randomized.

In the water tank, total of seven condition of ankle dorsal/planter flexion angle (maximal dorsiflexion, 15° dorsiflexion, 0° dorsiflexion/plantar flexion, 15° plantar flexion, 30° plantar flexion, 45° plantar flexion, and maximal plantar flexion) were formed by using goniometer (Fig. 1). On each condition, posterior ankle images were captured using ultrasonography (LOGIQ e Expert, GE Healthcare, Japan) in water (Fig. 2. A). One examiner positioned the transducer and optimized the quality of the image, and the same examiner captured and save the image. The probe position and gain of the ultrasonography system were fine-adjusted to display the outlines of tibia and calcaneus on the monitor.

After all measurement were finished, imaging analysis was held using the inbuilt ultrasound analysis software. Distance between the edge of the posterior tibial plafond and the superior calcaneus was measured on the sagittal plane using the inbuilt ultrasound analysis software (Fig. 2. B).

1.3. Statistical analysis

One-way ANOVA was used to compare the distance in the 8 angle conditions. When interactions were detected, further analysis was carried out using Scheffe’s test. P<0.05 was considered significant. All data analysis was performed using Statcel 2 (OMS-Publishing, Tokyo, Japan).

Fig. 1. Seven dorsal/planter flexion angles were determined by a goniometer. (DF: dorsiflexion, PF: plantar flexion)



A B Fig. 2. A: Scanning image in water bath.

B: Ultrasonographic image of posterior ankle region (Ti: Tibia, Ta: Talus, C: Calcaneus).

Results

Distance between the posterior tibial plafond and superior calcaneus decreased as ankle plantar flexion angle increased (men: 53.4±4.4 to 22.8±2.7 mm, women: 50.6±2.4 to 22.5±2.5 mm, Tab. 1). There were no significant difference of distance between men and women on each 7 angles. Significant shortening for distance between tibia and calcaneus was apparent between maximal dorsal flexion and 30° plantar flexion (p<0.05). There was not significant difference between 30° plantar flexion and 45° plantar flexion, 30° plantar flexion and maximal plantar flexion, 45° plantar flexion and maximal plantar flexion. Maximal angle of ankle dorsiflexion and plantar flexion of male subjects were 32.4±5.3° and 53.1±4.8°, respectively. Those of female subjects were 31.2±5.8° and 58.9±5.8°, respectively.

Tab. 1. Distance between the tibia and calcaneus.

Max DF 15° DF 0° DF/PF 15° PF 30° PF 45° PF Max PF

Men 53.4±4.4 47.5±4.3* 41.2±3.9*,† 33.0±3.9*,†,‡ 27.2±3.3*,†,‡,§ 24.0±3.1*,†,‡,§ 22.8±2.7*,†,‡,§

Women 50.6±2.4 46.6±2.9* 41.0±3.5*,† 34.5±4.2*,†,‡ 28.1±2.8*,†,‡,§ 24.4±2.9*,†,‡,§ 22.5±2.5*,†,‡,§

DF: dorsiflexion, PF: plantar flexion, Mean ± Standard Deviation

*: statistical difference between Max DF, †: statistical difference between 15° DF

‡: statistical difference between 0° DF/PF, §: statistical difference between 15° PF

Discussions

PAIS is recognized as chronic pain in athletes, such as soccer players and ballet dancers [7] [8]. Although there are some research that observed posterior ankle region of PAIS patients using MR or radiographic, or arthroscopic image, but the study that observed posterior ankle image using ultrasonography are less [3] [8] [9]. To our knowledge, this is the first study investigated the change of distance between tibia and calcaneus in posterior ankle region by using ultrasonograpy.

The distance between tibia and calcaneus was shortened with increasing ankle plantar flexion angle within the range from maximal dorsiflexion to maximal plantar flexion (men: 53.4±4.4 to 22.8±2.7 mm, women: 50.6±2.4 to 22.5±2.5 mm). As the hypothesis, the distance between the tibia and calcaneus is shorten as the ankle plantar flexion angle increases. The shortening of distance between tibia and calcaneus might indicate the findings of mechanism, which can cause posterior ankle impingement. There is a possibility that if some tissues are entrapped between them, symptoms of PAIS occur [1] [3]. In this study, all participants had no history of ankle injury before this measurement. Though some impingement may be observed dynamically in patients with PAIS by ultrasonographic assessment.

In spite of healthy participants, the distance was not shortening significantly between 30° plantar flexion and 45° plantar flexion, 30° plantar flexion and maximal plantar flexion, 45° plantar flexion and maximal plantar flexion. It indicated that the distance between tibia and calcaneus was not shortened further after 30° plantar flexion. Repetitive ankle plantar flexion is generally considered the risk factor of PAIS [1] [5]. Therefore, the certain contact or impingement could have already occurred after 30° plantar flexion in the ankle posterior region without any pain, and it may cause PAIS conclusively. It may be the mechanism to develop PAIS by athletes to repeat the ankle plantar flexion.

Previously, a radiographic study reported that approximately 70% of total plantar flexion was attributable to the talocrural joint, with the remaining 30% coming from motion between adjacent of the studied foot bones [10]. For this reason, after the ankle plantar flexion angle was increased from 30° and distance between tibia and calcaneus was no longer change, there was a possibility that the movement of the mid foot and forefoot greatly affected, such as Talus-Navicular, Navicular-Cuneiform, and Cuneiform-Metatarsal joint.

Although this study gives many suggestions about the dynamics of the posterior ankle region due to the movement of the ankle plantar flexion, there are some limitations in this study. The site just where PAIS really occurs was out of the immediate sight by using ultrasonography. 3D-2D model registration techniques was used to determine hind foot kinetics during the weight bearing activity from 20° dorsiflexion to 15° plantar flexion by using fluoroscopic images [11]. However the posterior ankle kinetics of larger plantar flexion angle, such as



PAIS may occur, was not discussed. In further study, the comparison with other diagnostic image, including CT and MRI, should be indicated to reveal usability of such ultrasonographic assessment.

Conclusions

The shortening of distance between the posterior tibial plafond and the superior calcaneus, it may causes Posterior ankle impingement was detected by using ultrasonography. After 30° ankle plantar flexion, certain contact or impingement could have already occurred in the ankle posterior region.

References

[1] Giannini S, Buda R, Mosca M, Parma A Di Caprio F. (2013). Posterior Ankle Impingement. Foot Ankle Int 34(3), pp. 459-465

[2] Rathur S, Clifford PD, Chapman CB. (2009). Posterior ankle impingement: os trigonum syndrome. Am J Orthop 38(5), pp. 252-253

[3] Robinson P, Bollen SR. (2006). Posterior ankle impingement in professional soccer players: effectiveness of sonographicallyguided therapy. Am J Rad 187(1), pp. W53-58

[4] Sasadai J, Urabe Y, Maeda N, Shinohara H, Fujii E, Takai S. (2013). The effect of ankle taping to restrict ankle plantar flexion on soccer instep kicks. Jpn J Clin Sport Med 21(3), pp. 694-701 (in Japanese)

[5] Lerch S, Kasperczyk A, Warnecke J, Berndt T, Rühmann O. (2013). Evaluation of Cam-type femoroacetabular impingement by ultrasound. Int Orthop 37(5), pp. 783-788

[6] Robinson P. (2007). Impingement syndrome of the ankle. Eur Radiol 17(12), pp. 3056-3065 [7] van Dijk CN. (2006). Anterior and posterior ankle impingement. Foot Ankle Clin Am 11(3), pp. 663-683 [8] Calder JD, Sexton SA, Pearce CJ. (2010). Return to training and playing after posterior ankle arthroscopy

for posterior impingement in elite professional soccer. Am J Sport Med 38(1), pp. 120-124 [9] Peace KA, Hillier JC, Hulme A, Healy JC. (2004). MRI features of posterior ankle impingement

syndrome in ballet dancers: a review of 25 cases. Clin Radiol 59(11), pp. 1025-1233 [10] Russell JA, Shave RM, Kruse DW, Koutedakis Y, Wyon MA. (2011). Ankle and Foot Contributions to

Extreme Plantar-and Dorsiflexion in Female Ballet Dancers. Foot Ankle Int 32(2), pp. 183-188 [11] Yamaguchi S, Sasho T, Kato H, Kuroyanagi Y, Banks SA. (2009). Ankle and subtalar kinematics during

dorsiflexion-plantarflexion activities. Foot Ankle Int 30(4), pp. 361-366



Influence of Difference in Knee Alignment on Site of Pain after Walking

Sogabe A.1

1Education and Research Center for Sport and Health Science, Konan University, (Japan) e-mail: [email protected]

Abstract

【Background and study aim】In this study, focusing on the individual difference in the characteristics of the knee joint, which plays an important role in weight bearing during walking, we examined the relationship between difference in knee alignment and pain in the legs during walking.【Material/Methods】A total of 40 subjects, including 25 healthy men and 15 women were recruited to this study. Knee alignment was classified according to the intercondylar and intermalleolar distances by increments of 2.0 cm. After walking (85km) on day 3 of the 5-day event, subjects were required to answer a questionnaire asking where in the leg they had pain.

【Results】The following sites exhibited significant differences in the number and incidence of injury between groups: the anterior side of lower leg (p <0.05), posterior side of lower leg (p <0.01), ankle joint (p <0.05) and sole of foot (p <0.01). 【Conclusions】When performing an exercise that places load on the legs, such as walking, one should consider the risk of injury by measuring the individual’s knee alignment before commencing the exercise.

Keywords: genu varum, genu valgum, injury, overuse.

Introduction

Walking is generally recommended as a safe and effective aerobic exercise, and has been shown to be effective not only for burning fat but for prevention of such diseases as coronary heart disease, hypertension and diabetes [1, 2, 3]. Its effect on reduction of medical expenses is also attracting attention [4]. However, walking involves repeating the same movement for a sustained period of time and thus is associated with the risk of overuse of bones, muscles and tendons of the legs. Indeed, a close relationship between physical activity and occurrence of orthopedic diseases has been suggested [5]. Exercise performed to improve health may, in fact, cause orthopedic disease and in such cases continuation of the exercise is discouraged. A study to determine the maximum pressure exerted on the femorotibial joint during walking revealed that walking at a rate of 1.4 m/s exerts a force 4.6 times the body weight on the joint [6]. One of the conditions caused by this mechanism is knee osteoarthritis (OA). A previous study reported that OA can occur in 10% of individuals aged 55 years or older and may result in a reduction in the amount of exercise performed due to pain and functional disorder [7]. Pain in the knee joint can be caused by change in knee alignment and load exerted on the joint, such as body weight load [7]. A study has demonstrated that load exerted on the medial side of the knee joint due to joint malalignment [8] accelerates the progression of OA [9]. In addition to direct influence on the knee joint, knee malalignment also affects muscles and tendons; it alters the muscles activated during weight bearing [10] and causes some muscles to be locally stiffened following exercise [11]. Therefore, if a person with knee malalignment performs an exercise that involves repetition of a simple movement, such as walking, he or she may become unable to continue to perform the exercise due to localized pain.

In this study, focusing on the individual difference in the characteristics of the knee joint, which plays an important role in weight bearing during walking, we examined the relationship between difference in knee alignment and pain in the legs after walking. On the basis of the results, we aimed to propose an effective and safe method of walking by measuring knee alignment prior to exercise in order that injury can be prevented.

Methods



Subject

A total of 40 subjects, including 25 healthy men (age: 21.2 ± 1.6 years, height: 170.4 ± 5.5 cm, weight: 67.3 ± 11.8 kg) and 15 women (age: 21.1 ± 0.7 years, height: 156.7 ± 5.3 cm, weight: 54.2 ± 7.8 kg) who had no previous medical history involving the legs and who participated in the walking event (5 days/4 nights: total walking distance is 140km) were recruited to this study. Knee alignment was classified according to the intercondylar and intermalleolar distances by increments of 2.0 cm. Subjects with an intercondylar distance of <2.0 cm with an intermalleolar distance of <2.0 cm were considered to have normal knee, those with an intercondylar distance of ≥2.0 cm considered to have genu varum, and those with an intermalleolar distance of ≥2.0 cm considered to have genu valgum. Subjects with genu varum accounted for 40% (16 subjects), those with normal knee accounted for 35% (14 subjects), and those with genu valgum accounted for 25% (10 subjects) of all subjects.

The study protocol was approved by the Human Ethics Committee of Konan University. Prior to participation, the risks and benefits of the study were thoroughly explained to all subjects and written informed consent was subsequently obtained.

Investigation of post-walking pain

After walking (85km) on day 3 of the 5-day event, subjects were required to answer a questionnaire asking where in the leg they had pain. We decided to carry out the investigation after the walking on day 3 based on the finding that delayed-onset muscle soreness (DOMS) reaches its maximum intensity between 24 and 72 hours after exercise [16, 17, 18, 19]. To exclude pain caused by scratches and blisters as examples, a separate section was provided for subjects to describe the site of these injuries. In addition, to prevent statistical errors due to difference in the subjects’ knowledge about technical terms, an illustration of the human body was provided for subjects to mark the site of pain, along with a list of the types of pain (e.g. muscular pain, indefinite complaint, sprain, strain, swelling, stiffness and others) for their selection. Injury-related pain, such as pain resulting from sprain, was excluded from the obtained data and only data concerning overuse-related pain were collected. The number of pain episodes in each group was then determined from the collected data, and the number of episodes per subject was calculated by dividing it by the number of subjects. We also examined the relationship between site of pain and knee alignment by determining whether the site of pain differs among subjects, using the Kruskal-Wallis test. Significant differences were further assessed using a multiple comparison test.

Results

The number of episodes of pain per subject in each knee-alignment group was as follows: 2.4 episodes/subject in the genu valgum group, 2.2 episodes/subject in the genu varum group and 1.5 episodes/subject in the normal knee group, with no significant differences between groups. Table 1 summarizes sites and numbers of injury in each knee-alignment group, incidences of each injury per subject, and percentages of injury associated with each site relative to the total number of episodes in each group, which was calculated by dividing the number of injury episodes in each group by the total number of injury episodes in each site. The following sites exhibited significant differences in the number and incidence of injury between groups: the anterior side of lower leg (p <0.05), posterior side of lower leg (p <0.01), ankle joint (p <0.05) and sole of foot (p <0.01). The number and incidence of injuries in the anterior side of lower leg were significantly higher in the genu valgum group than in the genu varum group (p <0.05) (Fig.1-a); those in the posterior side of lower leg were significantly higher in the genu valgum group than in the other two groups (p<0.01) (Fig.1-b); those in the ankle joint were significantly higher in the genu varum group than in the other two groups(p <0.05) (Fig.1-c); and those in the sole of foot were significantly higher in the normal knee and genu varum groups than in the genu valgum group (p <0.01)(Fig.1-d).

Tab. 1. Difference in knee alignment and sites of injuries



Fig. 1 Comparison of incidence of disorders in different sites

Discussion

There should be less structure-related local stress exerted on the knee joint for healthy and free bipedal walking throughout life. In persons with normal knee alignment, walking exerts a force approximately 3.2 times the body weight on the knee, and 70% of the impact is absorbed in the medial knee [9]. The genu varum in the frontal plane exerts pressure on the medial knee [20] and therefore poses a high risk of knee damage [21,22]. Continuously performing physical activities such as walking in the presence of genu varum and disadvantageous knee structure increases the risk of degenerative disorders of the knee [23]. Moreover, continuously performing exercise in the presence of knee malalignment can cause an increase in Q-angle, thereby generating large force by the quadriceps femoris muscles that pull the patella outward, resulting in knee pain [24]. Therefore, difference in knee alignment probably alters the site of load application and patterns of muscle activity. A study measuring the electromyogram activities of leg muscles during exercise in subjects with different knee alignment has shown different patterns of leg muscle activity among subjects[10], and another study measuring the hardness of leg muscles after exercise as a measure of fatigue in subjects with different knee alignment has also shown different patterns among subjects [11]. These findings indicate that different knee alignment can lead to load application at different sites even during transient exercise. It is thus likely that even during walking, different knee alignment leads to load application at different sites. In this study, the subjects in the normal knee and genu varum groups complained of pain in the sole of foot, and this is probably due to repeated application of stress and impact on the plantar aponeurosis during contact-toe off via the windlass mechanism. In persons with genu varum, the hardness of the muscles on the sole of foot significantly increases after leg presses [11]. In this case, excessive pronation of the ankle joint under load, which has been confirmed on video images [10], may be causing extension of the plantar aponeurosis. In contrast, in the genu valgum group, while none of the subjects



complained of pain in the sole of foot after walking, the incidence of pain significantly differed between the anterior and posterior sides of lower leg. In persons with genu valgum, since the center of the knee joint is located medial to the Mikulicz line [25], valgus moment is easily generated in the knee joint during the stance phase. This results in meidal rotation of the femur, pronation of the foot [26], and pulling of the muscles on the posterior side of the lower leg. This mechanism might have resulted in load on the triceps surae muscle and tibial anterior muscle, which are posture supporting muscles.

Conclusion

Although a number of studies have been conducted on the effect and method of walking, none of these studies has given detailed consideration to individual physical characteristics, which may be one of the factors causing injuries and hindering the continuation of regular exercise. When performing an exercise that places load on the legs, such as walking, one should consider the risk of injury by measuring the individual’s knee alignment before commencing the exercise.

site of pain and knee alignment by determining whether the site of pain differs among subjects, using the Kruskal-Wallis test. Significant differences were further assessed using a multiple comparison test.

References

[1] Hakim A.A., Curb J.D., Petrovitch H. et al. (1999). Effects of walking on coronary heart disease in elderly men: the Honolulu Heart Program. Circulation 100, 9-13.

[2] Lee I.M., Rexrode K.M., Cook N.R., Manson J.E. Buring J.E. (2001). Physical activity and coronary heart disease in women: is "no pain, no gain" passé? Journal of the American Medical Association 285, 1447-54.

[3] Manson J.E., Hu F.B., Rich-Edwards J.W. et al. (1999). A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. The New England journal of medicine. 341,650-8.

[4] Wang G., Zheng Z.J., Heath G., Macera C., Pratt M., Buchner D. (2002). Economic burden of cardiovascular disease associated with excess body weight in U.S. adults. American journal of preventive medicine. 23, 1-6.

[5] Macera C.A., Jackson K.L., Hagenmaier G.W., Kronenfeld J.J., Kohl H.W., Blair S.N. (1989). Age, physical activity, physical fitness, body composition, and incidence of orthopedic problems. Research quarterly for exercise and sport. 60, 225-33.

[6] Simonsen E.B., Dyhre-Poulsen P., Voigt M., Aagaard P., Sjøgaard G.., Bojsen-Møller F. (1995). Bone-on-bone forces during loaded and unloaded walking. Acta anatomica. 152, 133-42.

[7] Wluka A., Forbes A., Wang Y., Hanna F., Jones G., Cicuttini F. (2006). Knee cartilage loss in symptomatic knee osteoarthritis over 4.5 years. Arthritis research & therapy. 8, 90.

[8] Hurwitz D., Ryals A., Case J., Block J. and Andriacchi T. (2002). The knee adduction moment during gait in subjects with knee osteoarthritis is more closely correlated with static alignment than radiographic disease severity, toe out angle and pain. Journal of orthopaedic research 20, 101–107.

[9] Schipplein O.D. and Andriacchi T.P. (1991). Interaction between active and passive knee stabilizers during level walking. Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 9, 113-9.

[10] Sogabe A., Mukai N., Shimojo H., et.al. (2003). A genu varum effects on each lower extremity muscle activity during leg press exercise. Japanese Journal of Physical Fitness and Sports Medicine. 52, 275-284.

[11] Sogabe A., Mukai N., Shimojo H., et al. (2003). Genu varum effects on muscle hardness of lower limb after leg press exercise. The Journal of Japanese society of clinical sports medicine. 11, 518-525.

[12] Abraham W.M. (1977). Factors in delayed muscle soreness. Medicine and science in sports. 9, 11-20. [13] Armstrong R.B. (1984). Mechanisms of exercise-induced delayed onset muscular soreness: a brief

review. Medicine and science in sports and exercise. 16, 529-38. [14] Cleak M.J., Eston R.G. (1992). Delayed onset muscle soreness: mechanisms and management. Journal of

sports sciences. 10, 325-41. [15] Miles M.P., Clarkson P.M. (1994). Exercise-induced muscle pain, soreness, and cramps. The Journal of

sports medicine and physical fitness. 34, 203-16. [16] Kettelkamp D.B., Wenger D.R., Chao E.Y., Thompson C. (1976). Results of proximal tibial osteotomy.

The effects of tibiofemoral angle, stance-phase flexion-extension, and medial-plateau force. The Journal of bone and joint surgery. American volume. 58, 952-60.



[17] Chao E.Y., Neluheni E.V., Hsu R.W., Paley D. (1994). Biomechanics of malalignment. Orthop Clin North Am. 25, 379-386.

[18] Hewett T.E., Lindenfeld T.N., Riccobene J.V., Noyes F.R. (1999). The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. The American journal of sports medicine. 27, 699-706.

[19] Felson D.T., Zhang Y., Hannan M.T., et al. (1997).Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis and rheumatism. 40, 728-33.

[20] Powers C.M., Maffucci R. and Hampton S. (1995). Rearfoot posture in subjects with patellofemoral pain. The Journal of orthopaedic and sports physical therapy. 22, 155-60.

[21] Mikulicz J. (1878). Ueber individuelle Formdifferenzen am Femur und an der Tibia des Menschen. Mit Berucksichtigung de Statik des Kniegelenks. Arch Anat Entwicklungsgesch, 351.

[22] Donald A. (2002). Neumann Kinesiology of the Musculoskeletal System. Mosby Inc., St. Louis.



Psycho-Social Factors Promoting Psychological Acceptance of

Athletic Injuries

Tatsumi T.1, Takenouchi T.2

1 Faculty of Education, KIO University, (JAPAN) 2 Research Center of Health, Physical Fitness and Sports, NAGOYA University, (JAPAN)

e-mail:[email protected]

Abstract

[Aim] Psychological acceptance of athletic injury is characterized by 2 perspectives: Self-Motivation (SM) and

Focus on the Present (FP). Factors related to developing psychological acceptance of athletic injury in athletes are in the

process of being clarified. The purpose of this study was to develop a scale based on 3 perspectives: Emotional Stability (ES),

Sense of Unity with the Team (SUT), and Temporal Perspective (TP), and to examine the relationship between these

psychosocial variables and psychological acceptance of athletic injury. [Methodology] Participants were student-athletes (N =

133) that had experienced injury-rehabilitation after entering university. They were asked to fill out an originally developed

questionnaire that consisted of the following scales: the Psycho-Social Factors Scale (PSF-S) based on three perspectives

extracted from interviews. Participants also completed the Athletic Injury Psychological Acceptance Scale (AIPA-S).

[Results] Factor analysis using the principal factor method and Promax rotation conducted on the 22 items of the PSF-S

extracted four factors: ES: α= 0.854, Self-competence in the team (SCT): α= 0.837, TP: α= 0.847, and Communication with

Teammates (CT): α = 0.822. Results of conducting a similar factor analysis on the AIPA-S extracted the two factors: SM: α=

890 and FP: α=.673. Next, the influence of the four PSF-S subscale scores on the two AIPA-S subscale scores was investigated

by conducting covariance structure analysis. Results of examining the model in relation to the path coefficient between

significance variables (p<.05) indicated the influence of SM in the following order: TP (0.50), ES (0.40), and SCT (0.11).

Moreover, the influence was FP was identified in the following order: ES (0.56), CT (0.20), and TP (0.14). The model also had

a high index of fit (χ2=1.82, df=3, n.s.; GFI=.995; AGFI=.968; RMSEA=.000). [Conclusion] It is important to constantly

monitoring the temporal perspective and emotional recovery process of injured athletes.

Keywords: Psychosocial factors, Athletic injury psychological acceptance, Promotion factor

Introduction

Psychological acceptance of athletic injury has been defined as the psychological state in which an injured athlete

recognizes the severity of an injury and tries to find ways of coping with the injury and rehabilitation (Tatsumi and Nakagomi,

1999). Two perspectives have characterized psychological acceptance of athletic injury: “Self-Motivation (SM)” and “Focus

on the Present (FP).” Tatsumi (2013) suggested a relationship between these two variables of psychological acceptance of

athletic injury and dedication shown for rehabilitation. SM indicates the degree to which an athlete understands and is aware of

the purpose and meaning of the rehabilitation that she/he is undergoing. FP indicates an athlete’s perception that she/he cannot



currently play sports and is making a conscious effort during the rehabilitation process. Factors related to further development

psychological acceptance of athletic injury are still under investigation.

The purpose of this study was to develop a scale based on the three perspectives explicated by Tatsumi and

Nakagomi (1999): “Emotional Stability (ES)”, “Sense of Unity with the Team (SUT)”, and “Temporal Perspective (TP),” and

to examine the causal relationship between these psychosocial variables and psychological acceptance of athletic injury.

Method

1. Participants: It was predicted that the degree of injury and the level of dedication for sports would affect

the psychological effects of injury. Therefore, participants were recruited based on the following conditions.

Athletes that had experienced refraining from athletic activities for at least one week and had participated in athletic-

rehabilitation after entering university.

Athletes that had returned to athletic activities before at least one week, and were not currently undergoing athletic-

rehabilitation.

University student athletes in physical education departments that were inclined to do athletics and have a relatively

long career in athletics.

The selected participants were student-athletes (N = 133: Mean Age, 20.21 years, SD=1.07; Mean number of weeks

after stopping sports was 7.97, SD=11.26).

The Kio University Research Ethics Committee approved this study.

2. Questionnaires: The following questionnaires were used in the assessment.

1) Psychosocial Factors Scale (PSF-S): A provisional version of the PSF-S in which 24 items assessed the

there perspectives, ES, SUT, and TP described above.

2) Athletic Injury Psychological Acceptance Scale (AIPA-S): AIPA-S consists of 7 items measuring the level

of psychological acceptance of sports injury, composed of two subscales: Focus on the present and Self-motivation.

Tatsumi (2013) established the reliability and validity of this scale.

The response format for the PSF-S and AIPA-S were altered to the 7-point Likert scale ranging between 1 (not at all)

to 7 (very much). Participant that had two or more injury experiences in the past were requested to respond to the scale after

recollecting one injury experience that had left a deep impression on them.

Results

IBM SPSS 20.0 Statistics and Amos 20.0 was used for statistical analysis.

1. Reliability and Validity of the Scales:

Criteria for factor validity in the factor analysis described below were based on the Kaiser-Guttman rules. Selected

factors had an eigenvalue above 1.0, an absolute value of factor loading above 0.40, a high degree of commonality, and

appropriate content that fitted the factor name. Reliability was measured by calculating α coefficients using Cronbach’s

equation for internal consistency.



PSF-S: As a result of item analysis based on I-T correlation and G-P analysis, the validity of 23 items, with the

exception of item 7 (Feelings are strained) was confirmed. Next, factor analysis using the principal factor method and promax

rotation was conducted, which indicated that ‘PSF-S’ consisted of 4 factors: ES: α=0.85, Self-competence in the team (SCT):

α=0.84, TP: α=0.85, and Communication with teammates (CT): α=0.82 (Table 1). These results suggested the effectiveness of

the approach separately for the two factors: Communication with teammate, indicating the recovery of communication based

on affirmative feelings of teammates, as well as Self-competence in the team, indicating recovery of self-competence for team

management and for the relationship with coach, which is related to the perspective of Sense of unity with the team that was

assumed when the scale was first envisaged.

AIPA-S: Similar to a previous study (Tatsumi, 2013), factor analysis using the principal factor method and promax

rotation indicated that ‘AIPA-S’ consisted of two factors, SM: α=0.89 and FP: α=0.67 (Table 2).

The results of the statistical tests fully support the reliability and factorial validity of PSF-S and AIPA-S.

（N=133）Factors and Items (α=.89) F1 F2 F3 F4

F1 Emotional Stability: ES (8 items: α=.85)I don't hurry 0.87 0.00 -0.10 -0.05 0.64I don't feel pressure 0.72 -0.04 -0.08 -0.09 0.42I am not in a hurry and try to begin at my own pace 0.71 0.04 0.10 -0.08 0.55I am calm 0.63 -0.01 0.18 0.10 0.64I don't hesitate 0.60 0.07 0.17 -0.07 0.47

※ I am not imaginable of the future, and uneasy. 0.57 0.02 -0.04 0.11 0.38I am not shocked 0.57 0.00 -0.18 -0.12 0.21

※ It confuses my mind 0.51 -0.06 0.02 0.24 0.42F2 Self-competence in the Team: SCT (5 items: α=.84)

The team leader understands me well 0.02 0.79 0.04 -0.25 0.55My opinion is considered in team activities 0.00 0.77 -0.04 0.04 0.60I think that I am a good team member -0.02 0.73 0.01 0.14 0.63As the team leader, I can talk without constraints 0.04 0.68 -0.12 0.02 0.44I think of myself as a person needed by the team -0.02 0.62 0.13 0.08 0.50

F3 Temporal Perspective: TP (4 items: α=.85)The goal is reached gradually -0.05 -0.08 0.87 -0.10 0.61I try to work positively in my own way 0.00 -0.07 0.80 0.08 0.66I will do what I can do for the team -0.12 0.12 0.76 -0.02 0.56I try to begin with what is possible to do now in my own way 0.03 0.01 0.75 -0.01 0.58

F4 Communication with teammates: CT (5 item: α=.82)I am satisfied with my interpersonal relationships with teammates -0.10 -0.15 -0.03 0.96 0.74I am satisfied with the relationship with my teammates 0.06 -0.04 -0.06 0.78 0.59I have the colleague who tells worry in the team -0.13 0.10 0.05 0.63 0.43My team values players with an individual will -0.03 0.31 -0.08 0.52 0.43I can adapt myself to the interests of the team 0.27 0.04 0.14 0.44 0.51

Correlation coefficient F1 - 0.21 0.55 0.46F2 - - 0.34 0.40F3 - - - 0.47

Table 1. Results of factor analyzing Psychosocial Factors Scale (PSF-S)Factor loadings

Communality

※Reversing score item

（N=133）Factors and Items (α=.86)

F1 Self-Motivation: SM (3 items: α=.89)I understand what I need to do to move forward 0.87It is clear to me what I have to do now 0.82I have come to terms with the past and am focused on the present 0.57

F2 Focus on the Present: FP (3 items: α=.67)※ I want to run away from my current situation 0.43※ I am still worrying about the past and cannot move forward 0.35

I don't have any worries and am positively accepting my current situation 0.54

I am clarifying what I can do now and what I cannot do and planning ahead 0.47Correlation coefficient F1

0.35 0.39- 0.67

※Reversing score item

(Remainder Item)

-0.08 0.71-0.03 0.610.31 0.49

1.01 -0.130.93 -0.030.63 0.18

Table 2. Factor analysis result concerning Athletic Injury Psychological Acceptance Scale (AIPA-S)Factor loadings

CommunalityF1 F2

（Psycho-Social Factor ）（Psychological Acceptance Factor ）

ES: Emotional stability

SCT: Self-competence in the team SM: Self motivation

CT: Communication with teammates FP: Focus on the present

TP: Temporal perspective

Figure 1. Covariance structure analysis Result

e1

e2

.44

.42

.28

.19

.39

.40

.40

.56

.11

.50.20

.14

.64

.57

χ2=1.82, df=3, n.s.; GFI=.995; AGFI=.968; RMSEA=.000



2. Psycho Social Factors promoting Athletic Injury Psychological Acceptance

The influence of the four subscale scores of the PSF-S on the two subscale scores of AIPA-S was examined by

conducting a covariance structure analysis. It was assumed that there was a covariance between the four PSF related to

exogenous variables. Moreover, it was assumed that there was a covariance between the errors of each variable related to the

degree of the correlation (r=0.58, p=0.00) between the SM factor and the FP factor related to AIPA-S of endogenous variables.

Analysis was repeated until goodness of fit continuously reached the highest value by deleting non-significant paths. As can be

seen in Figure 1, the goodness of fit index of the model was high (χ2(3)=1.82 (n.s.), GFI = 0.995, AGFI = 0.968, RMSEA =

0.000). Results of examining the model in relation to the path coefficients between significance variables (p<.05) related to SM

indicated the degree of influence in the order of TP (0.50), ES (0.40), and SCT (0.11) and related to FP in the order of ES

(0.56), CT (0.20), and TP (0.14). The relative comparison of the path coefficients suggested that "ES" strongly promoted an

AIPA focus, and "TP" strongly promoted SM related to AIPA. It is concluded that ES and TP related to PSF promote AIPA.

Conclusion

It is important to constantly monitoring the temporal perspective and emotional recovery process of injured athletes.

References

１) Tatsumi T, Nakagomi S: A study on psychological acceptance to injury in athletes: Analysis from the viewpoint of

athletic-rehabilitation behavior. Japan Journal of Sport Psychology, 1999, 26: 46-57.

２) Tatsumi T: Development of athletic injury psychological acceptance scale. Journal of Physical Therapy Science, 2013,

25: 545-552.

３) Ryan RM, Deci EL: Overview of self-determination theory: An organismic dialectical perspective. In: E.L. Deci and

Ryan (Eds): Handbook of self-determination research. University of Rochester Press, 2002, 3-33.



Association between altered pelvic tilt and hamstring strain among rugby palyers (case in kandy district, Sri Lanka)

Wickramasinghe Y.M.N.M, Buddhika W.H.S.W.R, Paththuwage R.G, Weerasinghe W.C.S, Wijayalath W.P.L.K, Udyakumari A.D.M.

Faculty of Allied Health Science, University of Peradeniya, Sri Lanka

Summary

Rugby is a contact sport which involves many lower limb movements. Lower limb injuries account for over 50% of all injuries and hamstring injuries are the second most common injury among rugby players. As this injury reduces the performance of the players, early diagnosis and taking remedial measures are of paramount importance. This study used a convenient sample of 180 school rugby players and 6 of them were excluded during the exclusion process. A field survey and specific orthopedic assessments were held to collect data and Chi- Square test was used as analytical tools. It was found that, 57% and 4% of the players are with anterior and posterior pelvic tilt respectively. Of the players, 13% were with hamstring strain. Based on the results, it is also possible to conclude that hamstring strain holds no direct association between either form of pelvic tilt (P<0.01). However, as this study did not consider the behavioral and environmental factors repeating the study incorporating those aspects is recommended.

Introduction

The muscle contraction is the mechanism that provides energy for the movements of the body. Any problem in muscle contraction will reduce the physical efficiency of human beings. Similarly, hamstring strain is an injury to any muscle or tendon in hamstring group which could reduce the performance of humans and it specially affects rugby players as it is a sport which involves many lower limb movements. Thus, early diagnosis of the problem and taking remedial measures are of paramount importance.

Hamstring Muscles

Hamstring muscles are combination of three muscles (i.e. Semimembranosus, Semitendinosus and Biceps Femoris) contains a high proportion of fast twitch type II muscle fibers. All muscles are attached proximally to the ischial tuberosity except for the short head of biceps femoris which is originated at the linea aspera and lateral supracondylar line of the femur. Semitendinosus is attached to the medial surface of the superior tibia, semimembranosus to the posterior aspect of the medial condyle of the tibia and the oblique popliteal ligament, while biceps femoris is attached to the lateral side of the fibula. Semitendinosus, semimembranosus and long head of biceps femoris are innervated by the tibial division of the sciatic nerve and the short head of the biceps femoris is innervated by common fibular nerve. Bicep femoris flexes the leg at the knee joint, extends and laterally rotates the thigh at the hip joint and laterally rotates the leg at the knee joint. Semimembranosus and Semitendinosus flexes the leg at the knee joint and extend the thigh at the hip joint, medially rotate the thigh at the hip joint and the leg at the knee joint (Richard et,al,2007).

When workload exceeds the tolerance level of hamstring muscles it causes injuries to this muscle / tendon and is known as Hamstring Strain and this is the second most injury reported by the rugby players (Gibbs, 1994). According to, Opar et. al (2012), Hamstring Strain could also be occurred due to anatomical factors such as biarticular organization, duel innervation of biceps femoris, fiber type distribution, muscle architecture, poor lumbar posture and the degree of the anterior pelvic tilt and other possible reasons are age, previous injuries, inadequate fitness, lack of proper worm up, strength imbalances between quadriceps and Hamstring muscles, reduced Hamstring strength and endurance, lack of Hamstring and quadriceps flexibility, reduced strength and coordination of pelvic and trunk muscles, inadequate eccentric hamstring strength to counteract concentric quadriceps action in terminal swing phases of running, fatigue and postural abnormality. Therefore, under stressful and rapid situations like sports, when a muscle failed in performing a particular action,



the muscle could be subjected to damages. The Biceps femoris is the muscle that is often subjected to damages and such damages, based on the clinical features can be categorized as grades I, II and III (Brotzman and Kewin, 2003).

Pelvic Tilt

Normally the Anterior Spuerior Illiac Spine of the pelvis line is on a horizontal line with the Posterior Spurior Illiac Spine and on a vertical line with the Symphysis Pubis, and any deviation from the normal position will cause an altered pelvic tilt (anterior or posterior). So, the altered pelvic tilt is a motion of the entire pelvic ring in the sagittal plain around a coronal axis. The normal ranges of anterior pelvic tilt for males and females are 9.6 ± 3.5 and 11.0 ± 3.8 respectively (Mckeon and Hertel, 2009). As long as this angle is within the normal range, the movement is considered as a normal anterior pelvic tilt and any deviation beyond that range is considered as an altered pelvic tilt. The abnormal anterior pelvic tilt is resulted from one of the combinations of tight hip flexors or erector spinae muscle and weakened and lengthened abdominal or hamstring muscle. Anterior pelvic tilt produces hip flexion. In hip flexion the Anterior Superior Iiliac Spine moves interiorly and the inferiorly while sacrum moves further from femur.

Any angle of posterior pelvic tilt is considered as an altered pelvic tilt (Levangie and Norkin, 2005). The abnormal Posterior Pelvic Tilt is resulted from one of the combinations of the combinations of tight abdominals or hamstring muscles and /or weakened and lengthened hip flexors or erector spine muscles (Lippert, 2006). Posterior pelvic tilt produces hip extension. In hip extension symphysis pubis moves up and the sacrum comes closer to the femur.

As altered pelvic tilt, especially the degree of anterior pelvic tilt is categorized as a risk factor for hamstring strain many studies were focused on the association of hamstring extensibility and length with pelvic position, but none has paid attention to the relationship between the Hamstring Strain and altered pelvic tilt.

Since the altered pelvic tilt is having negative impacts on hamstring muscle, objectives of this study were to determine the frequency of occurrence of anterior pelvic tilt and posterior pelvic tilt among rugby players and to examine whether the anterior pelvic tilt and posterior pelvic tilt of rugby players were associated with hamstring strain.

Material and method

A convenient sample of 180 rugby players above 17 years of age were selected from 8 schools in Kandy district as it is the most famous district for rugby. During the exclusion process 6 players were dropped and the balance 174 was used in the research. Detailed physical assessments done examining the clinical performance of the players and using specific orthopedic tests ( Passive Straight Leg Raising Test, Resisted Knee Flexion, Slump Test and Sit and Reach Test). The range of motion of lower limb joints, muscle power around hip and knee joint muscles and angle of pelvic tilt were also recorded. Meter stick, Goniometer and caliper were the instruments used in taking measurements of the players.

The meter stick trigonometric method suggested by Sanders and Stavrakas (1981) was used to measure the angle of pelvic tilt. Reliability of this method had proven and thus, it is an acceptable method. The trigonometric procedure used is explained below.



The range the motion was measured positioning the patient and placing the goniometer over the accurate point on each joint and the stable and movable arms of the goniometer aligning according to the slandered method. Muscle strength was measured using the Manual Muscle Testing technique.

Results and conclusions

Results revealed that, 57 % and 4% of the players were with anterior and posterior pelvic tilt respectively. Thus, it is possible to conclude that anterior pelvic tilt is more common among rugby players. One of the research hypotheses was that there is no association between hamstring strain and anterior pelvic tilt. The Chi- square test at 0.01% level of significance was used for this purpose. Calculated value of the Chi-square was 0.48 and that was smaller than the critical value (6.63) and therefore the hypothesis was accepted. It indicates that, anterior pelvic tilt and hamstring strain are not associated. The next hypothesis tested was there is a relationship between posterior pelvic tilt and hamstring strain, Chi- square test at the same level of significance was used for this purpose too. The calculated and critical values of Chi- square were 3.99 and 6.63 respectively. Therefore it is possible to state that there is no statistical evidence to reject the null hypotheses at 0.01 % level of significance. Finally, based on the results, it is concluded that neither anterior pelvic tilt nor the posterior pelvic tilt is associated with hamstring strain.

As this study did not consider the behavioral and environmental factors of the players it is suggested to repeat the study incorporating those aspects.

References

BROTZMAN,S.B AND WILK, K.E. Clinical Orthopedic Rehabilitation (2nd edition ) Philadelphia: The Curtis Center, Pennsylvania. 2003.

GIBBS, N, Common Rugby League Injuries; Recommendations for Treatment and Preventive Measures. Sports Med. 18 (6): 67 – 81.1994

LEVANGLE, P.K AND NORKIN ,C.C. Joint Structure and Functions: A Comprehensive Analysis. (4th edition). Philadelphia: F.A.Davis Company.2005.

LIPPERT, L.S. Clinical Kinesiology and Anatomy (4th edition). Philadelphia: F.A.Davis Company.2006 MCKEON, J.M.M. AND HERTEL, J. Sex Differences and Representative Values for Lower Extremity

Alignment Measures. Journal of Athletic Training, 44 (3):249- 55. 2009. Opar, D.A, Williams, M.P, and Shield, A.J. Hamstring Strain Injuries; Factors that lead to Injury and Re-injury.

Sports Med. 42(3):209- 26. 2012.




© Medimond . Q926S7019 95

The effects of musical tempo during cycling exercise among undergraduate sport science students

Illias N.F., Adnan R., Ross V., Sulaiman N., Appukutty M.

Rahmat ADNAN Accredited Exercise Physiologis - Faculty of Sports Science & Recreation - Universiti Teknologi MARA Shah Alam - Malaysia Email: [email protected] / [email protected] - Telephone: 60355211893 Fax: 60355442910

Abstract

This study was conducted in order to investigate the effects of different musical tempo during cycling exercise. Twenty male undergraduate sport science students’ with mean age: 21.60 ±1.60 years, weight: 63.35 ±7.80 kg, height: 170.32 ±5.92 were voluntarily participated in this study. All subjects were involved into experimental studies using aerobic cycling exercise; fast and slow musical gamelan tempo and no music group respectively. The cycling exercise group was evaluated using following parameters: Heart rate, rating perceived exertion (6-20 Borg scale), feeling scale, distance pedalled and handgrip strength. Participants were completed cycling for 20 minutes at self-paced intensities. Wilcoxon Signed Ranks Test was used to measure the outcomes of this study due too small samples size. The result of this study found heart rate was significant higher when listening to fast musical gamelan tempo compare to slow musical gamelan tempo. Furthermore, RPE scale was significant higher when listen to fast musical gamelan tempo compare to no music. Moreover, feeling scale was good when listening to fast musical gamelan tempo compare to slow musical gamelan tempo and no music. Listening to no music was increase the distance pedalled when comparing to the slow musical gamelan tempo and no significant effect listening to fast musical gamelan tempo. Hence, this study suggests listening to fast musical gamelan tempo may influence or enhance the aerobic cycling performance.

Keywords: Fast musical gamelan tempo, slow musical gamelan tempo, heart rate (HR), rating perceived exertion (RPE), feeling scale (FS), distance pedalled (DP).

Research Background

Presently, Waterhouse, Hudson, and Edwards (2010), suggested music can cause positive effects when listening at the same time of physical activity is performed. Thus, listening to the music during exercise maybe can enhance the individual to cope more efficiently with exercise modalities and with specific exercises that eliminate or evoke feeling of pain (Koç & Curtseıt, 2009). According to the Kelly and Kristal (2010), many fitness instructors considered the addition of music during exercise give similar effect like ergogenic effect on performance.

Music can be inspirational to some people because music provide an important beneficial effect to the exercise and sport experience (Kelly & Kristal, 2010). In fact, with the current technology exist such as MP3 players, I-Pod and Zunes, music and more make people are more accessible and convenient using this device while exercise (Kelly & Kristal, 2010). Besides that, music proven can increase enjoy and happy arousal of individual when engage with group session of exercise such as aerobic dance, Yoga, Pilates and etc (Kelly & Kristal, 2010).

Moreover, past studies found music had narrows a performer’s attention and divert the sensation of fatigue to excitement mood during exercise. In addition, they also reported music enhanced the positive dimensions of mood and alters the temper from negative dimensions to positive dimension. According to Mohammadzadeh, Tartibiyan, and Ahmadi (2008) their study summarized that music can alter psychomotor arousal eventually can act either as a stimulant or sedative.

Previous studies by Karageorghis et al.,(2009), its showed that by using motivational synchronous music can elicit an ergogenic effect and enhance in task effect during an exhaustive endurance exercise. According to Attila Szabo (2004), it proved while listened to slow musical tempo it decrease the quality of the training. In contrast, they also reported, listening to the fast musical tempo boost the quality of training. This similar to the studies by Seath and Thow (1995) and A. Szabo, Small and Leight (1999), when listening to fast musical tempo while performing aerobic exercise it made positive feeling state.



In contrast, some study was declared when listening to the fast musical tempo does not enhance the exercise performance. According to Copeland and Franks (1991), reported in study conducted by Koç and Curseit (2009), listening to the loud and fast musical tempo did not enhance physiological and psychological responses during submaximal exercise. For instance, according to Schwartz et al., 1990, reported in the study conducted by Ghaderi, Rahimi, and Ali Azarbayjani (2009), listening to the music while performing the exercise did not affected the exercise performance.

Research Objective

1.1 To compare the effects of different musical tempo listened between fast, slow musical tempo and no gamelan tempo (no music) during cycling exercise on heart rate (HR), rating perceived exertion (RPE), feeling scale (FS) and distance pedaled (DP).

1.2 To compare the effects of different musical tempo listening between fast, slow musical tempo and no gamelan tempo (no music) during physical strength.

Method

Participants: Twenty undergraduates male students were required to take part in two experimental conditions: fast and slow musical gamelan tempo and no music (control group). At least 48 hours later a second cycling session was performed by each participant. This case is to make a comparison between two treatments given and one control group. This is to determine whether there was a significant difference when listened to the difference musical tempo and no music during cycling exercise and physical strength.

Sampling technique: This study used purposive sampling technique for only 20 participants from UiTM undergraduates sport science students that actively involved in physical activity at least three times per week with age range between 20 to 26 years of age

Research design: This study used quasi-experimental design to achieve its objective. Twenty undergraduates male students were undertaken into two experimental studies: fast musical gamelan tempo, slow musical gamelan tempo and no music (control group). None of the participants were involve in regular medication, musculoskeletal injury and cardiovascular disease prior of this study. Professional cyclists that represented for state or national team were excluded from this study.



Figure 1: Conceptual research framework

20 participants

Rest at least 48 hours between trails

Active healthy male students

Undergraduate Sport Science students from UiTM Shah

Listening the fast musical gamelan tempo while cycling 20 minutes

Listening the slow musical gamelan tempo while cycling 20 minutes

Listening the no music while cycling 20 minutes

Cycling Physical strength

Listening the fast musical gamelan tempo while performing

handgrip strength test

Rest for 30 seconds

Listening the slow musical gamelan tempo while

performing handgrip strength

Listening the no music while performing handgrip strength

test

Rest for 30 seconds

Rest at least 48 hours between trails



Outcome measures: This study aims to investigate the acute effect of musical tempo during cycling exercise. Therefore, this study encompasses three different musical tempos between four dependent variables of outcomes measure during cycling exercise. The outcomes measures are exercise heart rate, rate perceived exertion, feeling scale, rate of pedal cadence and handgrip strength (Figure 2):

Figure 2

Musical tempos – fast, slow and no

music.

1. Exercise Heart rate

2. Exercise RPE 3. Exercise Feeling

scale 4. Rate of cadence 5. Handgrip strength

Cycling exercise

Independent variables

Dependent variables

RESULT

Wilcoxon Signed Ranks Test

Instrumentation: Climatic chamber in UiTM Shah Alam was used to maintain the room temperature for this study. Throughout the study environment within the laboratory remained at room of temperature 26 - 29° C. Testing equipment and scoring procedure were calibrated and set up before the test begin .

This study was used Monark Pendulum Cardio Care 827 E (made in Sweden). Monark Cardio Care 827 E measure a total distance pedalled by the each participant during 20 minutes of cycling exercise. Participant’s listened to special tempo-composed of gamelan music during their cycling sessions using MP3 player Philips (GoGear) and a headphone (Ultimate technology HM-550). A stopwatch was used to set and record the duration of cycling time.

Heart rate watch and monitor (RS-100 Polar) were used to record the activity of the heart beat at constant rate of cycling exercise. Moreover, perceived rating exertion (RPE) Borg 20 scale and feeling scale (FS) by Hardy and Rajeski, 1989 was used as additional parameter of this study.

Music composition: This study used cross-discipline research with researcher from Faculty of Music UiTM for special tempo composition using gamelan melody by Associate Professor Dr. Valerie Ross. Furthermore, the use of this gamelan-tempo is to measure heart rate, rating perceived exertion, feeling scale and distance pedalled during cycling exercise.

In this study, each of the 20 participants exercised for 20 minutes per session for a total of 3 sessions. In the first session they listened to digital gamelan music (‘saron’) played using only 4 pitches in fast tempo (‘allegro’ at 138 beats per minute). In the second session they listened to digital gamelan music (‘saron’) played using only 4 pitches in slow tempo (‘adagio’ at 60 beats per minute). The third session represented the control group where there was no music played during exercise session..

The music was composed using sound samples recorded at 44.1kHz and at a sample rate of 16 bits. Each sample was recorded individually on the Korg Krome keyboard which was then patched into ProTools 9. The sound used to achieve this gamelan sound that was closest to the ‘Saron’ was called the 'Gamelon' in the keyboard settings.

Each sample was recorded once, and then repeated over and over again in order to reach the required 20 minutes of playback. Each sample was the compressed and normalized to ensure that there were no blips and clicks that could potentially compromise the quality of the recording. After all necessary samples were recorded, they were transferred into WAV format which was then further compressed into MP3 format.

Pre- test procedure: Prior of the test, all participants completed basic pre-test assessments. These includes signed in consent form and pre- screening for risk stratification using SMA-HMS UQ. Besides, the researcher take an opportunity to brief the participant clearly about the framework of the test is conducted. This



includes; protocol and procedure to handle the test equipment and tools using Monark Cardio Care 827 E, Rating Perceived Exertion (RPE) and feeling scale (FS).

The basic demographic profiles were taken such as weight (kg), height (cm) and age (year) during prior of this study. Furthermore, to ensure the proper cadence during the paddling the bike, each participant was informed to select their hip height level for cycling sitting height (ACSM 2006). All participants were instructed to wear the heart rate transmitter at the left side of the chest for constant Heart Rate monitoring during the test was conducted.

The heart rate maximum (HRmax) was calculated for each participant using age estimate equation (220 - age) as a baseline data. The training heart rate zone of the test was set up intensity from 55% to 69% HRmax based on the ACSM recommendation for moderate intensity. Resting heart rate was recorded in order to obtain the most valid moderate intensity which is in range 55% to 69% HRmax using Karvonen method. Training heart rate zone was calculated using Karvonent method equation [RHR + % intensity × (HR max - RHR)].

All participants were remained to refrain from heavy meals and stimulants such as caffeine substances for at least 4 hours prior to testing. In addition, participants were asked not to do heavy exercise 24 hours before the test session.

Experiment procedure: All the participants were performed three sessions adopted from Elliott et al 2005 protocol: fast and slow musical gamelan tempo and listen to no music. Schedule for the participants to perform the test was made. For the first session, all the participants had heard fast musical gamelan tempo, the second session all participants had heard slow musical gamelan tempo and the third session participants did not hear any music.

Each participant had been given time to perform 3 minutes warm up at a cadence of 50 repetition per minute (rpm), with resistance 1kp. Once the test protocol performed, participant was listened to the fast musical gamelan tempo using portable music device which is MP3 players Philips (GoGear) with headphone (Ultimate technology HM-550) at the standardise volume.

After warm up session, the test protocol begun. Participant was pedalled the bicycle at their self selected speed and gradient for 20 minutes. Participant’s heart rate (HR), rate perceived exertion (RPE), feeling scale (FS) and distance pedalled (DP) were recorded during 5 min, 10 min, 15 min and 20 min cycling. No encouragement or any other type of communication was given to the participants while they were cycling. Completion of the 20 minutes test was followed by a 3 minutes cool down performed at self selected intensities. The next two sessions continued with the same protocol but listened to slow musical gamelan tempo and listen to no music as a control group after rest at least 48 hours.


© Medimond . Q926S7019 100

Figure 3: Data collection procedure

Statistical analysis: This study utilized different group for two experimental conditions and one control

group. Two experimental groups enrol fast and slow musical gamelan tempo and the control group listen to no music during the experiment. An alpha of p<0.05 was set for all statistical test.

Descriptive statistics were calculated for all dependent variables. SPSS statistical software version 16.0 was used (SPSS Inc., Chicago,IL,USA) to analyze the data. The participants are lower than 30 (<30) in which according to Central Limit Theorem (CLT) lead to a non-normal distribution. For that matter, researcher was using the non-parametric test which is the Wilcoxon Signed- Rank test as an alternative for paired t test for parametric test.

Result

3 minute warm up at a cadence of 50 repetitions per minute (rpm), with resistance 1kp

Cycling for 20 minutes and HR, RPE, FS and Distance was recorded four times (5 min, 10 min, 15

min, 20 min)

When test begun, participant was pedaled at self selected speed and cadence base on their preferable

effort

Once the test protocol performed, the participant listened to the music using portable music device

which is MP3 players with headphone

Completion of 20 minutes cycle ergometer test, followed by 3 minute cooling down, perform at a

self selected intensity and speed


© Medimond . Q926S7019 101

This study used the Wilcoxon Signed-Rank Test as the nonparametric test equivalent to the dependent t-test. It is used to compare two sets of scores that comes from the same participants. Median score was used to know which musical tempo most affect the performance. The basic statistical parameters for all the data were also calculated: mean and standard deviation. The data was processed by means of the SPSS 16.0 statistical program.

Article 1_Table 1: Demographic factors of the participants

Article 1_Table 2: Mean and SD score for HR, RPE, FS and distance pedalled

Article 1_Table 3: Median score for HR, RPE, FS and distance pedalled

N Mean SD

Age (Years) 20 21.60 1.60

Body weight (kg) 20 63.35 7.80

Body height (cm) 20 170.32 5.92

HR RPE FS DP Physical strength

Mean SD Mean SD Mean SD Mean SD Mean SD

Fast musical gamelan tempo

5.23 2.27 33.7 7.02 18.7 8.49 15.5 3.13 39.24 6.16

Slow musical gamelan tempo

4.33 1.44 30.6 7.03 14.6 6.24 14.9 2.73 39.35 6.78

No music 4.76 1.99 30.1 6.49 14.5 5.26 16.5 1.71 39.05 6.21 HR RPE FS DP Physical

strength

Fast musical gamelan tempo

4.00 32.87 17.12 15.35 38.65

Slow musical gamelan tempo

3.50 30.62 13.87 14.08 39.35

No music 3.50 30.65 15.37 16.86 40.20


© Medimond . Q926S7019 102

Article 1_Table 4: Mean heart rate (HR)

Heart rate (HR): It was the intention of the researcher to assess HR. Base on Wilcoxon Signed Ranks Test showed that there were significant effect when comparing fast musical gamelan tempo vs. slow musical gamelan tempo which is (Z = - 2.006, P = 0.045). Base on median score, participants was preferred to listen to the fast musical gamelan tempo compare to slow musical gamelan tempo. But when compare to fast musical gamelan tempo vs. no music and slow musical gamelan tempo vs. no music showed that there is no significant different which are (Z = - 0.881, P = 0.378) and (Z = -1.172, P = 0.241).

Article 1_Table 5: Mean rating perceived exertion (RPE)

Rating perceived exertion (RPE): Base on Wilcoxon Signed Ranks Test showed that there was significant effect when comparing fast musical gamelan tempo vs. no music which is (Z = - 1.923, P = 0.054). Participants more preferred to listen fast musical tempo music compare to no music base on median score. There is no significant effect of different musical tempo listen toward rating perceived exertion when comparing fast musical gamelan tempo vs. slow musical gamelan tempo, (Z = - 1.873, P = 0.061) and slow musical gamelan tempo vs. no music (Z = -0.564, P = 0.573).

Article 1_Table 6: Mean feeling scale (FS)

Z score Asymp. Sig. (2- tailed)

Fast musical gamelan tempo vs. slow musical gamelan tempo

- 2.006 0.045

Fast musical gamelan tempo vs. no music -0.881 0.378

Slow musical gamelan tempo vs. no music -1.172 0.241


Fast musical gamelan tempo vs. Slow musical gamelan tempo

- 1.873 0.061

Fast musical gamelan tempo vs. no music -1.923 0.054

Slow musical gamelan tempo vs. no music -0.564 0.573


© Medimond . Q926S7019 103

Feeling scale (FS): Base on Wilcoxon Signed Ranks Test showed that there were significant effect when comparing fast musical gamelan tempo vs. slow musical gamelan tempo which is (Z = - 3.125, P = 0.002) and fast musical gamelan tempo vs. no music which is (Z = - 2.147, P = 0.032). That means, participants like to listen to fast musical gamelan tempo when compare to slow musical gamelan tempo and no music. There were no significant effect when listen to different musical tempo toward feeling scale when comparing slow musical gamelan tempo vs. no music which is (Z = - 0.174, P = 0.862) and median score indicate slow musical gamelan tempo spoiled feeling scale compare to no music.

Article 1_Table 7: Mean distance pedalled (km)

Distance pedalled (km): Base on Wilcoxon Signed Ranks Test showed that there were no significant effect when comparing fast musical gamelan tempo vs. slow musical gamelan tempo which is (Z = - 0.805, P = 0.421) and fast musical gamelan tempo vs. no music which is (Z = - 1.307, P = 0.191). But there were significant effect when listen to different musical tempo toward feeling scale when comparing slow musical gamelan tempo vs. no music which is (Z = - 2.147, P = 0.032). Median score shows that participants distance pedalled was farther during no music compare to slow musical gamelan tempo.

Discussion

The most interesting finding in this study was significant different when listening to the two different gamelan tempo and no music while performing cycling exercise towards HR, RPE, FS and PD.

Heart rate (HR): Analysis for the heart rate after twenty minutes cycling got favourable result. It was found that, there were significant effects when listening to fast musical gamelan tempo compare to slow musical gamelan tempo. Base on the median score, it demonstrates, participants were preferred to listened fast musical gamelan tempo. There was no significant effect when comparing fast musical gamelan tempo with no music, also slow musical gamelan tempo and no music.

Finding of the present study indicated, when listening to fast musical gamelan tempo participants preferred to work above the moderate intensity which is 55% to 69% HRmax that was setting by researcher. It can be concise that when listening to the fast musical gamelan tempo, participants were become more energetic and motivated to do cycling exercise. Hence, heart rate score was above the training heart rate zone for moderate intensity.



-3.125 0.002

Fast musical gamelan tempo vs. no music

- 2.147 0.032

Slow musical gamelan tempo vs. no music

-0.174 0.862



-0.805 0.421

Fast musical gamelan tempo vs. no music

- 1.307 0.191

Slow musical gamelan tempo vs. no music

-2.147 0.032


© Medimond . Q926S7019 104

This study was supported by the previous researcher. According to Karageorghis et al. (2009) when listening to fast musical tempo music which is >120 beat per minute considered as motivational music, it showed, participants heart rate were reached 193 beat per minutes which closed to the maximum heart rate. This finding also support by Birnbaum et al. (2009) which was significant increase in heart rate when participants listened to fast musical tempo during exercise. This finding also supported by Waterhouse et al. (2010) which by increased the beat musical tempo listened, mean for heart rate was increase 0.1% compare to the decreased beat musical tempo listened, mean score for heart rate was decrease 2.2%.

Heart rate finding in this study was contras to those reported by Young et al. (2009) as they said the heart rate was unaffected when listening to the music during exercise. According to Nicola A Schie (2008), it also shows that, the heart rate was unaffected when listening to the music when perform by professional cyclist. A possible reason for this contrast finding was differences in type of participants. Perhaps professional cyclists were more internally motivated and not focus on external stimuli. For this study, participants selected were active person and not professional cyclists that represented for state or national team. Possibly this study have an effect when listening to the music during cycling exercise because of the participants were sedentary people, who only involved at least three times per week.

High intensity training also was results unaffected on heart rate (Young et al., 2009). Their studies shows music was affected the cycling performance when it is done at moderate intensity. According to Rajeski (1985) in study conducted by Elliott et al. (2005) they suggested, working at high intensities reduced the impact of external stimuli. Consequently, for the present study, it is the possible factor there was an effect on heart rate because the researcher was set for moderate training heart rate zone. According to Ghaderi et al. (2009), at the lowest intensities, external cues such as music may become influential.

Rating perceived exertion (RPE): Finding indicated listening to fast musical gamelan tempo was significant effect when compare to no music. Base on median score, participants were preferred to listened fast musical gamelan tempo compare to no music. This is because, when listen to fast musical gamelan tempo, participants become more energetic and aggravated to increase their exercise intensities. Participants were preferred to increase their intensities those causes the increase the RPE scale. This finding supported by Waterhouse et al. (2010) as they indicated, when increase by 10% tempo listen from the normal tempo, mean score for RPE had increased 2.4 %.

Finding for present study also shows the same finding reported by Ghaderi et al. (2009) as they indicate, RPE scale was lowered when listening to relaxation music when compare to motivational music. According to Karageorghis et al. (2009), motivational music was determined when the tempo was >120 beat per minute. Finding for present study also show the same finding reported by Karageorghis et al. (2009), there were benefits derived from walking in synchrony with motivational music when compare with control condition.

Finding from present study was contrast to the study conducted by Nicola A Schie (2008). Finding from their study shows that, RPE scale was decreased when listen to the music. This is because of the participants selected were highly trained and disciplines cyclist. Similar finding reported by Young et al. (2009) when using professional participants, listening to music did not affect the athlete’s RPE during treadmill exercise.

Once again this may be related to the type of participants were selected. Assumption that can be made, athlete or professional cyclists were internally motivated. This finding also because, when performing the test, it did not challenge professional cyclist fitness level. As we notice that, athlete or professional cyclists training intensity was higher in order to maintain their performance. Therefore it might be the test was not challenging their fitness level and that reason RPE score was lower.

Feeling scale (FS): Participant’s feeling scale revealed that was significant effect when cycling while listen to fast musical gamelan tempo when comparing to slow musical gamelan tempo and no music. Base on median score, it shows, those participants were preferred to listen to the fast musical gamelan tempo. According to Seath and Thow (1995) in research conducted by A. Szabo, Small, and Leigh (1999), resulted stated that was positive feeling states in relation to fast musical tempo music during aerobic exercise were found.

This present finding was similar to the finding report by Karageorghis et al. (2009), the motivational music enhance feeling scale effect throughout the entire duration of task. This finding can be summarized that when listening to the fast musical tempo, participant feeling during exercise was good. Exercises while listen to fast musical gamelan tempo had made participants do not focused on feeling of fatigue and enjoy the exercise more.

For instance, according to Karageorghis and Terry (1997) reported in study conducted by Elliott et al. (2005), attending to musical stimuli may block the transmission of the internal sensation associate with physical activity, for example, fatigue and effort sense. This research also reported study done by Rajeski (1985) that was reported adopting an external focus can improve affect. This support the notion that although music not moderate what participant feels when working at high intensity exercise, it can moderate how one feel it by Rajeski (1989) in study conducted by Karageorghis et al. (2009).

Finding reported by Elliott et al. (2005) was measured feeling scale revealing that both music conditions which is motivational and non motivational music provoked significantly more positive mood. Although


© Medimond . Q926S7019 105

motivational music elicited the greatest increase in affect. But contra finding by the present study, it shows slow musical gamelan tempo impaired cycling performance when compare to no music. This maybe effect of slow gamelan tempo which is ≤ 60 beat per minutes. When listened to slow musical gamelan tempo participant may feel bored during cycling exercise.

According to Elliott et al. (2005) stated that, slow musical tempo can be played in the exercise environment without provoking a negative response. Slow musical gamelan tempo might be effective when listening during sport psychology for mental imagery purposes. This is because, commonly during imagery session, relaxation music or slow musical tempo was played in order to make sure athletes are purely relaxed.

Distance pedalled (DP): The results of present study indicate that, when compare to slow musical gamelan tempo and no music was significant different in distance pedalled during 20 minutes exercise. Base on the median score, it shows that participants pedalled were father when listen to no music. It is maybe associated with the RPE scale. When listened to fast musical gamelan tempo and slow musical gamelan tempo, participants were preferred to increase their exercise intensity. When increase exercise intensity it may result decrease distance pedalled.

For example when listened to fast musical gamelan tempo participants become more eager and provoked to increase their effort as they choose to increase the exercise intensity, then the RPE scale reported was slightly increase. Increase the exercise intensity likelihood may cause decrease distance pedalled. It should be noted that from conversation with some of the participants, comments were passes regarding their experience after listened to the different musical gamelan tempo, they was preferred to increase their exercise intensity indirectly their RPE scale was increase when listen fast musical gamelan tempo. Finding for present study shows that when gradient was increased that cause decrease distance pedalled. We recognize that inferences based upon conversation with participants cannot be advanced as ‘scientific’ explanation; nevertheless, researcher should perhaps consider the use of alternative assess distance pedalled related to exercise intensity.

Finding for present study was contradict with study reported by Elliott (2007) which their finding was significant increase distance pedalled when listening to fast musical tempo and moderate musical tempo and control condition. Finding by Elliott et al. (2005) also reported both motivational and oudeterous music elicited significant increase in distance travelled during a 20 minutes cycling exercise. According Waterhouse et al. (2010) their finding also reported there was increase the distance pedalled when listened to the music during exercise.

Maybe this finding report does not emphasize the exercise intensity that may interrupt distance pedalled. To see the effect of different musical tempo listened affect the exercise performance, then participants were ask to pedalled at self selected exercise intensity in term of speed and gradient. So, it is important to take consideration the speed and gradient pedalled because it can affect the distance pedalled.

Conclusion

Conclusion can be made, when listening to fast musical gamelan tempo, it caused participants able to train at higher training heart rate zone for moderate intensity. Participant level of effort also was increases by indicated using RPE scale. At the same time they feel good when doing exercise while listened to fast musical tempo. There was a connection between RPE scale and distance pedalled found in the present study. When listen to fast musical gamelan tempo, indirectly participants was motivated to increase their exercise intensity that caused decrease distance pedalled.

Finding of the present study shows that participants enjoyed cycling session with music more compare to without music. The music may have generated positive emotional states rather than acting purely as a disaster (Nicola A Schie, 2008). They also reported fifty seven per cent of participants found that music can act as stimulant which is cycling while listening to the music to be easier.

Acknowledgement

The researchers would like to express gratitude to the RMI (Research Management Institute) UiTM for funding this study.

References

1. Attila Szabo, Lorna. J. Hoban. Psychological Effects of Fast- and Slow-Tempo Music Hayed during Volleyball Training in a National League Team. Journal of Applied Sports Sciences. 2004;16(2), 39-48.

2. Birnbaum, L., Boone, T., Huschle, B. Cardiovascular Response to Music Tempo During Staedy-State Exercise. Journal of Exercise Physiology Online. 2009; 12(1), 50-57.


© Medimond . Q926S7019 106

3. Elliott, D., Carr, S., Orme, D. The effect of motivational music on sub-maximal exercise. European Journal of Sport Science. 2005; 5(2), 97-106.

4. Ghaderi, M., Rahimi, R., Ali Azarbayjani, M. The Effect of Motivational and Relaxation Music on Aerobic Performance, Rating Perceived Exertion and Salivary Cortisol in Athelete Meals. South African Journal for Research in Sport, Physical Education & Recreation (SAJR SPER). 2009; 31(2), 29-38.

5. Hardy, C. J., Rejeski, W. J. Not What, But How One Feels: The Measurement of Affect During Exercise. Journal of Sport & Exercise Psychology. 1989; 11(3), 304-317.

6. Karageorghis, C. I., Mouzourides, D. A., Priest, D.-L., et al. Psychophysical and Ergogenic Effects of Synchronous Music during Treadmill Walking. Journal of Sport & Exercise Psychology. 2009; 31(1), 18-36.

7. Kelly, B., Kristal, B. Enhancing Sports Performance Through The Use Of Music. Journal of Exercise Physiology Online. 2010; 13(2), 52-57.

8. Koç, H., Curtseıt, T. The Effects of Music on Athletic Performance. Ovidius University Annals, Series Physical Education & Sport/Science, Movement & Health. 2010; 9(1), 44-47.

9. Mohammadzadeh, H., Tartibiyan, B., Ahmadi, A. The Effects of Music on Perceived Exertion Rate and Performance of Trained and Individuals During Progressive Exercise. Facta Universitatis: Series Physical Education & Sport. 2008; 6(1), 67-74.

10. Nicola A Schie, A. S., Pieter Backer & Geoff G Rogers. Effect of music on submaximal cycling. South African Journal of Sports Medicin. 2008; 20.

11. Nicole M. Harmon, L. K., PhD. The Beat Goes On: The Effects Of Music On Exercise. IDEA Fitness Journal. 2008.

12. Szabo, A., Small, A., Leigh, M. The effects of slow- and fast-rhythm classical music on progressive cycling to voluntary physical exhaustion. Journal of Sports Medicine & Physical Fitness. 1999; 39(3), 220-225.

13. Waterhouse, J., Hudson, P., Edwards, B. Effects of music tempo upon submaximal cycling performance. Scandinavian Journal of Medicine & Science in Sports.2010; 20(4), 662-669.

14. Young, S. C., Sands, C. D., Jung, A. P. Effect of music in female college Soccer players during a maximal treadmill test. International Journal of Fitness.2009; 5(2), 31-36.

15. Elliott, D. Music During Exercise: Does Tempo Influence Psychophysical Responses? Philica.com. 2007.


© Medimond . Q926S7022 107

Acute changes in blood pressure after physical activities

Raja Yong S., Lee C.P., Moganan M., Misran M.H.I.

Company: Sport Research International Sdn. Bhd.

Abstract

Background

Statistic from Ministry of Health shows that only 25% of Malaysian people did the exercise and the rest of 75% passive lifestyle. There have many consequences by not doing the exercise such as cardiovascular disease, hypertension and diabetes. This study aimed to document the acute changes in blood pressure after physical activities and the duration of significant blood pressure reduction.

Method

Eleven subjects of normal blood pressure people with mean age 27. The method of sampling is randomized. All the subjects had undergone the 40 minutes of strengthening and aerobic exercise. The intensity of aerobic is determined by calculation of maximum heart rate (MHR) and training heart rate (THR). The aerobic session had breakdown into three phases which is warm up, aerobic and cool down. Moreover, the strengthening exercises focus on ten major group muscles. Blood pressure reading taken pre and post exercise.

Result

The result shows that significant reduction in blood pressure pre and post exercise (p=0.001). The mean value of blood pressure indicates sustain decrement on the systolic and diastolic pressure.

Conclusion

From the 11 subjects, there was a visible reduction in SBP and DBP, and exclusion of 5 subjects demonstrate significant drop in SBP and DBP. The experiment also demonstrates the lower reading lasted for period of 15 minutes.

Background

The effects of physical activities on clinical BP might be different in normotensive, hypotensive and hypertensive individuals because cardiovascular haemodynamics are modified by hypertension. The effects of aerobic and resistance exercise on Blood Pressure have different mechanical characteristics.The aerobics training is characterized by large muscle groups contracting at mild to moderate intensities for a longer period. Heart works harder to pump blood through the body more quickly more than the normal over extended period of time, so the left ventricle of the heart enlarges and increase in stroke volume, thus cardiac output also increases. The vasodilation of the artery happens increases the size of the lumen and thus reduces mean arterial pressure (MAP).

For resistance exercise ; the spike of heart beat (ejection fraction) during resistance training, will massage the vessel walls and nourishes the endothelial cells around the artery thus reducing the peripheral resistance resulting a lower BP and reduce in mean arterial pressure (MAP).Two hormones epinephrine and norepinephrine (the vasoconstrictors) on blood flow in the arteries also may effect in lowering BP. Aerobic exercise can reduce the blood level of norepinephrine which limits the vasoconstriction of arterioles, allowing for less peripheral resistance to BP. In addition, there is slight reduction in central nervous system (CNS) activity that may help to mediate this decrease in BP. Endurance training decreases blood pressure through a reduction in systemic vascular resistance, in which the sympathetic nervous system and the renin-angiotensin system appear to be involved, and favourably affects concomitant cardiovascular risk factors. The few available data suggest that resistance training can reduce blood pressure.


© Medimond . Q926S7022 108

Methodology

Subjects

A total of 11 subject participated in subjective assessment before proceed for the aerobic and strengthening. Subjects were excluded if they (1) had a history of cardiovascular or renal diseases or diabetes; (2) had electrocardiographic evidence of coronary heart disease or cardiac arrhythmia; (3) were hypertensive, as defined by currently using any antihypertensive medication (4) severe degenerative disease.Physical activities in this investigation are strength training and aerobic activities. Randomized samplings were used in subject selection. Each subject undergoes 40 minutes of aerobic and strength training exercises.

Blood Pressure Measurement

After a 5-min rest in the sitting position, blood pressure was measured three times during two different visits to the laboratory. On the occasion of each visit, blood pressure was measured by the same experienced observer using a digital sphygmomanometer. Subjects were excluded if the average of the last two values obtained during each visit for systolic and diastolic blood pressures was greater than 120 and 80 mmHg, respectively.

Training Heart Rate

The intensity of aerobic is determined by calculation of maximum heart rate (MHR) and training heart rate (THR). The aerobic session had breakdown into three phases which is warm up, aerobic and cool down. Moreover, the strengthening exercises focus on ten major group muscles. Blood pressure reading taken pre and post exercise.

Aerobic Training Strength Training

Intensity Dependant on activity level of subjects: Inactive (55 – 60%) Moderate (60 – 65%) Active (65 – 70%)

Exertive at the last 3-5 reps

Time 5 minutes (warm up) 20 minutes at THR 5 minutes (cold down)

3 sets of 10-15 repetitions 30 seconds in between sets

Type Treadmill/stationery bicycle Free weight (10 major muscles groups)

The mean age of subjects is 27 years. The heart rate and blood pressure readings are measured and taken during (1) pre workout and (2) immediate, 5 minutes, 10 minutes and 15 minutes post workout.

Results

Mean Value

No. of Subjects 5 MIN SBP/DBP(HR)

10MIN SBP/DBP(HR)

15MIN SBP/DBP(HR)

11 (Total) 11.27/4.18(4.18) 14.27/1.36(6) 14.09/2.36(1.54) 6 (BP) 16/5(7.33) 17.83/6.16(7) 19.33/6.33(3)


© Medimond . Q926S7022 109

P Value

Parameters 11 (Total) 6 (BP) HR 0.001 0.058

Diastolic 0.002 0.048 Systolic 0.041 0.041

P < 0.05 means significant changes

This study indicates significant changes in diastolic pressure and systolic pressure (p=0.048,p=0.041 p<0.05). The measurement taken for every 5 minutes, shows that blood pressure respond towards the physical activity. Nevertheless, the magnitude and the time course of blood pressure changes after exercise are inconsistent. In normotensives, the magnitude ranges from no change to falls as great as 30 mmHg.

Conclusion

The finding of this study was that structured and appropriate intensity of exercise give beneficial effect of acute changes. The progression and load for exercise program should be planned accordingly in order to avoid overtraining or overload. To prevent it, steady increase 5% of intensity of exercise should be implemented (Budgett, 1990). The determination of duration rest interval depends on the intensity level of exercise. Most studies dealing with post-exercise blood pressure responses have demonstrated that exercise reduces blood pressure during the recovery period (Forjaz, Matsudaira, Rodrigues, Nunes, and Negrão, (1998). It has been suggested that the development of hypertension is preceded by a prehypertensive state that may be manifested by abnormal cardiovascular reactivity to environmental and behavioral challenges (Miyai, et al, 2002).

Reference

MIYAI, N. , ARITA, M., MIYASHITA, K., MORIOKA, I., SHIRAISHI, T. and NISHIO, I. (2002) Blood Pressure Response to Heart Rate During Exercise Test and Risk of Future Hypertension, Journal of the American Heart Association, pp:761 – 766.

FORJAZ C.L.M, MATSUDAIRA, Y., RODRIGUES, F.M., NUNES, N. and NEGRAO, C.E (1998) Post-exercise changes in blood pressure, heart rate and rate pressure product at different exercise intensities in normotensive humans. Braz J Med Biol Res, Vol 31(10), p:1247-1255.

BUDGETT, R., (1990). Overtraining Syndrome. Br J Sports Med. Vol 24, p: 231-236.


© Medimond . Q926S7014 111

Explain the income strategies of sport clubs from view point of Tehran sport managers

Pirmohammadi M1, Omidzade Monfared M.1, Dehghani S.3

1-Department of physical education ,brujerdt Branch, Islamic Azad university,brujerd,Iran 3-Department of physical education ,Marvdasht Branch, Islamic Azad university,Marvdasht,Iran. Corresponding author, Email: [email protected]

Introduction

Sport as a means to achieve objectives such as growth and optimal body modification, motor skills, personality development, social progress and is targeted at the global level and the Olympics as a catalyst for progress, understanding and mutual respect among nations is used There are many people all over the world. Sports industry and its territory all around the world quickly subdued. (5) The economic aspects of the media industry with virtually all groups of clothing, food and equipment are intertwined and can include direct impacts on production, production services, sports tourism, exports of goods, a Places facilities advertising participation In the stock market, attracting tourists and sponsors, create jobs, increase economic growth, health promotion and ... Indirect effects include reduced treatment costs, increase efficiency and reduce manpower and enriching leisure crime is affecting the national economy (5).

Methodology

The study was descriptive and causal - comparative (after the event) and the functional purpose of the field survey data for this study were collected through a questionnaire. To study all the data of Sports and Physical Education Department staff in Tehran marketing managers and directors of football federations, weightlifting, wrestling, basketball and took the form of research, they go to work, they managed to collect 80 questions with multiple was. Due to the limited sample population includes all population is measured by means of a questionnaire survey.Findings and conclusions based on the results of 75 exams between 10 and 20 years of management experience, but only 25 /% of subjects older than 20 years of management experience 10 percent of their degree and 25/86% of subjects undergraduate and graduate only 75/3% of them had a PhD. Of the subjects, 75/38 percent footballer, 5/22 vector wrestler 25%, 75/13% of basketball players and 25/71 per cent of respondents were male and 75/28% of them were women. First, determine the normal distribution of data, the Kolmogorov - Smirnov was used.

Results of the analysis using Friedman rank test, are given in Table 1-1

Sports site to attract supporters 23/57,26/4

Sponsorship of sporting events taking place 00000/1

12/4

Commercial use when sponsoring cultural exhibition tournament 45/3

Top of the credit institution Sport 38/3

The use of sponsors in sports broadcasting 93/2

Attracting foreign investment 86/2

Between the various elements of compensation Clubs of marketing (product), there is no significant difference.


© Medimond . Q926S7014 112

Table 1-2Dimensions of the priority Average Rating significant chi-square value

Sporting goods (balls, clothes, ...) 31/74 ,

85/4

To recruit famous players around the world 46/4

Granting exemptions, fiscal, trade, customs investors 35/4

Buy tickets for the team 16/4

Female viewers are sports fields, 93/3

Sales at the Stock Exchange Club 83/3

Buy clothes Players Championship after 43/2

Conclusion

Our findings indicated that income among various sports clubs, sponsors and advertising and marketing is of primary importance are the next priorities.

Athletic directors from the perspective of the country - the most effective roles in advertising revenue sports clubs, "the media advertising sales, ticket sales during competitions, advertising on sports clothing, selling newspapers and magazines owned club, the use of the interviews and media publicity surrounding land, the right to sell albums, calendars and books are the results of this study Rod Nuts uprising was born as advertising around the pitch, or field dress, one of the main sources of income drinks to sports clubs or individuals (7) and 6 and divine concluded an obstacle to economic development industry football media player is (2) and Farley (8), (4) in their research, such as that advertising One of the most important revenue channels and media in sports, they are consistent (8)., but these findings with the results of Moharram Khalifa (7), Morgan due to different countries as well as research and study of Vngrshshan Advertise categories inconsistent. (9) The results of research findings by Ramazani, based on the economy and investment in sports that do not comply may no agreement could be attributed to differences in the subject of study by society. (7).The most important and effective role in marketing revenue sports clubs, sports products (balls, clothes, ...), to serve the rest of world famous players, teams and competitions with the world further communication with the bus business While Japan Karate Federation the marketing and sports marketing unit of the Federation, other than the above production method, such as sports, will earn (6) Vale of the lack of agency, and human resources marketing specialist <br> Sports and formulation of strategic plans and marketing operations in the football industry in such problems are a major revenue sports clubs (4).

Resources

1- Atqya’, N., (1384). Interactivity Marketing, Sports Management, Sports Science Institute Journal of Research in Physical Education and Sports Science Research, Ministry of Science and Technology. The first year, the number one.

2- Ehsani, M., (1382). Sports Marketing Manager, Middle East Congress High H. (collection of articles). Tehran. 3- Lord, A., M., (1369). From production to consumption, marketing, publications December. 4 - bachchehaye, M., (1380). Propaganda in the media and its impact on consumer decision-making goods and

services, Proceedings of the First International Conference on the advertising industry.


© Medimond . Q926S7014 113

5- Izadi, A., (1384). Describe factors Brjzb requirement sponsoring companies sponsoring professional football in Iran, the Graduate School of Physical Education and Sport Sciences, Tarbiat Moallem University of Tehran.

6 - Hassanzadeh, M., (1384). Sports marketing, publishing issue. 7 - Rahimi Boroujerdi, A., (1385). Privatization, Tehran University Press, first edition. 8 - Razavi, MH, (1383). Improve performance in sports privatization policy, the Journal, No. 23. 9 - Razavi, Mohammad Hossein, (1383). Privatization policy analysis with emphasis on the sport of athletics,

Ph.D. Dissertation in Sport Management, Faculty of Physical Education and Sport Sciences at Tehran University.

© Medimond 115

Author Index

Adnan R., 95 Appukutty M., 95 Balakrishnan B., 25 Buddhika W.H.S.W.R, 91 Chee Keong Chen, 1 Ch’ng Ls., 3 Dehghani S., 111 Fujii E., 65, 77 George J., 3, 9 Hamid Msa, 3 Hodgson L., 19 Illias N.F., 95 Inal H.S., 23 Jaafar Z., 3 Kadoguchi T., 73 Kinugawa S., 73 Kotoshiba S., 65 Kubo Y., 69 Lal P.R., 25 Lee C.P., 107 Maeda N., 65, 77 Mah LHK, 59 McKune A. J., 39 Misran M.H.I., 107 Moganan M., 107 Morita N., 73 Moriyama N., 65 Nagahama H., 69 Okita K., 73 Omidzade Monfared M., 111 Ong K., 43

Paththuwage R.G, 91 Pirmohammadi M, 111 Raja Yong S., 107 Ross V., 95 Sasadai J., 65, 77 Sasaki S., 69 Shariff AH, 47 Shinohara H., 65, 77 Singh R., 51 Sogabe A., 81 Subasi F.., 55 Suga T., 73 Sulaiman N., 95 Takada S., 73 Takenouchi T., 87 Taniura T., 73 Tatsumi T., 87 Toh TH, 59 Tsutsui H., 73 Udyakumari A.D.M., 91 Urabe Y., 65, 77 Weerasinghe W.C.S, 91 Wickramasinghe Y.M.N.M, 91 Wijayalath W.P.L.K, 91 Yamamoto T., 65 Yokota T., 73