Introduction to Sport and Exercise Medicine

Question 1

Coursework notes

Answer 1

• Formative assessment:
• For feedback & developmental purposes: does not contribute to module mark. * Structured essay plan: 400 words
• Submission by: Friday 28th October 2022 by 4 pm (by email to c.byrne3@exeter.ac.uk) * 2-min PowerPoint presentation of evidence foundation
• Submission by: Wednesday 2nd November 2022 (upload file to ELE site in ‘Assessment Information & Submission’ section.
• Presentations delivered Thursday 3rd November 12:30-14:30
• Summative Assessment:
  Essay: 3250 words
• Contribution: 100% of module mark
• Essay title: ‘With reference to specific examples, evaluate the application of evidence from sport and exercise medicine in the provision of multidisciplinary support to elite performers’.

5 content sections:
1. Select, define, and justify a specific athletic or military population to focus the essay on.
2. Demonstrate a critical awareness of the specific considerations for the sport and exercise medicine support team in the management of this population.
3. Critically evaluate evidence of the factors limiting performance in this population.
4. Critically evaluate evidence of the factors influencing injury and illness in this population. - major injuries with numbers
5. Critically evaluate how the multidisciplinary sport and exercise medicine support team can utilise evidence to maximise human performance and to prevent and/or optimally manage sport or exercise related injuries and illnesses in this population.

Try to use systematic reviews and meta analysis

Question 2

Reading to do this week

Answer 2

Brukner & Khan Chapter 1: Sport and exercise medicine: the team approach p(2-8)

• Dijkstra et al (2014). Managing the health of the elite athlete: a new integrated performance health management and coaching model. British Journal of Sports Medicine, 48; 523-31.

Recommendation: Investigate your own professional scope of practice, tasks and responsibilities e.g. physiotherapist, strength & conditioning coach, sport scientist etc.

Question 3

WHat’s a health problem?

Answer 3

Any condition that reduces an athlete’s normal state of full health, irrespective of its consequences on the athlete’s sports participation or performance or whether the athlete sought medical attention.
* An umbrella term that includes, but is not limited to, injury and illness.

Question 4

Injury definition?

Answer 4

Injury is tissue damage or other derangement of normal physical function due to participation in sports, resulting from rapid or repetitive transfer of kinetic energy.

Injury may be categorised as either acute or overuse, based on the mechanism of injury and rapidity of symptom onset (Brukner & Khan, 2017).

Note: Kinetic energy is identified as the ‘agent’ of injury with synonymous terms commonplace in the literature (e.g. force, stress, strain, impact).
* All of these terms can be considered as examples of ‘load’ or ‘loading’.

Question 5

Illness defintion?

Answer 5

Illness is a complaint or disorder experienced by an athlete, not related to injury.
* Illnesses include health-related problems in physical (e.g. influenza), mental (e.g. depression) or social well-being, or removal or loss of vital elements (air, water, warmth).

Question 6

What’s an acute injury?

Answer 6

• Refers to an injury that occurs during a single, identifiable traumatic event.
• Arises when force applied to tissue generates stresses and/or strains that are greater than the tissue can withstand.
• Result is tissue failure generating macroscopic damage and rapid onset of symptoms, such as pain and loss of function.

Question 7

What’s an overuse injury?

Answer 7

• Overuse injuries have a gradual onset with an underlying pathogenesis of repetitive micro trauma (Neil et al. 2018).

Question 8

Epidemiology definition?

Answer 8

Study of how often injuries occur in different groups of athletes and why.

Question 9

Prevelance definition?

Answer 9

Number of existing cases of an injury in an athletic population at or over a given time.

Question 10

Incidence defintion?

Answer 10

Number of new cases of injury in an athletic population relative to exposure.

Question 11

Severity definition?

Answer 11

Nature of injury, timeloss, cost.

Question 12

Burden definition?

Answer 12

Incidence x severity: time loss, cost.

Question 13

Risk factor definition?

Answer 13

Why a particular athlete may be at risk in a given situation.

Question 14

Injury mechanisms/ causes?

Answer 14

How injuries happen.
* A person, thing, event, state or action that produces an effect. * Aetiology,pathogenesis,mechanisms.

Question 15

van Mechelens’s sequence of prevention model?

Answer 15

1. Establish the extent of the injury (incidence and severity)
2. Establish the aetiology (cause) and mechanisms of the injury
3. Introduce a preventive measure
4. Assess its effectiveness by repeating step 1

Question 16

Meeuwisse’s Multifactorial Model

Answer 16

“To the casual observer, athletic injuries may appear to be accidents – random, serendipitous events. However, many factors play a role before the actual occurrence of the injury event.”

Intrinsic (Internal) Risk factors
* Previous injury
* Age
* Sex
* Body size & composition
* Biomechanics
* Physical fitness (aerobic, flexibility, balance, strength etc.)

Extrinsic (External) Risk factors
* Weather
* Playing surface
* Rules, rule enforcement * Protective equipment
* Opposition behaviour

1. 2.
   Meeuwisse’s Multifactorial Model

Intrinsic risk factors predispose an athlete to injury
* Predisposed athlete: insufficient to cause injury alone
Predisposed athlete exposed to extrinsic risk factors
* Susceptible athlete: insufficient to cause injury alone * Sum of risk factors and complex interaction
* “Accident waiting for a place to happen”

Inciting event
* “Final link in the chain or web of causation”
* Directly associated with onset of injury
* Final inciting event typically receives most focus
* May (acute injury) or may not be (overuse injury) the most important event

Question 17

Bahr & Krosshaug’s Inciting Event & Comprehensive Injury Causation Model?

Answer 17

“A precise description of the causative event is critical”
* “The key point to consider with regard to biomechanical factors is that they must explain how the event either resulted in a mechanical load in excess of that tolerated under normal circumstances or reduced the tolerance levels to a point at which a normal mechanical load cannot be tolerated.”
* “The ultimate goal is to use this information to develop specific preventive measures for a specific injury type, perhaps even in a specific sport.”

Question 18

Bahr & Krosshaug’s View on Injury Mechanism

Answer 18

• The term ‘‘injury mechanism’’ is used to describe:
  a) Vital aspects of the playing (sports) situation: the situation
  described from a sports specific point of view
  b) Athlete and opponent behaviour: a qualitative description of the athlete’s action and interaction with the opponent
  c) Gross biomechanical characteristics: a description of whole body biomechanics
  d) Detailed biomechanical characteristics: a description of joint/tissue biomechanics.

Question 19

Summary of Bahr & Krosshaug’s Model

Answer 19

“A precise description of the inciting event is a key component to understanding the causes of any particular injury type in a given sport.”
* “It is necessary to expand the traditional biomechanical approach to describing the inciting event, if the objective is to prevent injuries.”
* “A complete description of the mechanisms for a particular injury type in a given sport needs to account for the events leading to the injury situation (playing situation, player and opponent behaviour), as well as to include a description of whole body and joint biomechanics at the time of injury.”
* “To address the potential for prevention, the information on injury mechanism must be considered in a model that also considers how internal and external risk factors can modify injury risk.”

Question 20

Define Evidence based practice?

Answer 20

It’s the integration of best research evidence with clinical expertise and patient values

Question 21

What is an evidence pyramid or hierarchy of evidence?

Answer 21

From least important adding to quality of evidence to most important:

Background information/expert opinion

Case-controlled studies and case series/reports

Cohort studies

Randomised controlled trials

Systematic reviews (best)

Question 22

What is risk of bias?

Answer 22

he likelihood that features of the study design or conduct of the study will give misleading results.

Question 23

What is a risk of bias assessment tool and can you name 2 assessment tools?

Answer 23

All RCTs indexed on the PEDro database are rated for Page 12methodological quality. In practice, this means that trained raters have gone through every trial and scored whether it satisfies each of a list of criteria (the PEDro scale) that are reported on the PEDro website. (www.pedro.org.au).

The Cochrane risk of bias tool has many commonalities with the PEDro scale and is used to assess the quality of trials in many Cochrane reviews. Each item of the quality scale relates to an issue that could result in biased study results; for each criterion that is not met, the risk that the study results are biased is greater. Examples of items that might bias a study result include:

whether the researcher deciding whether patients were included in the study knew to which group they would be assigned (concealed allocation)
whether the intervention and control groups were comparable at baseline
whether a large proportion of the patients who began in the study remained until follow-up was complete.

^^^List at least 3 risk of bias assessment items that assess the quality of evidence?

Question 24

Sport Injury and illness Epidemiology types?

Answer 24

Injury & illness definitions, injury & illness type & location (e.g. muscle strain, ligament sprain, knee, ankle, affected system, symptoms), mode of onset (acute, repetitive, sudden, gradual), mechanism of onset (contact, non-contact, overuse/repetitive with gradual onset), severity of injury & illness (time loss), injury & illness prevalence, injury & illness incidence, relative risk (incidence rate ratio)

Question 25

Expressing athlete risk?

Answer 25

1) Prevalence measures (proportion %, over a specified time period)
* Most appropriate for gradual-onset conditions (e.g. asthma, patellar tendinopathy).
2) Incidence measures (rates, number per exposure)
* Most appropriate for sudden-onset conditions (e.g. ankle sprains, ACL injuries).

Question 26

Prevelance definition?

Answer 26

• Prevalence is the number of existing cases of a disease or injury divided by the total population at risk at a given point in time.

Question 27

Incidence defintion?

Answer 27

Incidence refers to the number of new cases that develop over a specified period of time or per unit of exposure.

Question 28

IOC Consensus Statement on Epidemiological Methods (Bahr et al. 2020)

Answer 28

*“Important questions that sports injury and illness surveillance projects are designed to address include:
* What is the risk of an individual athlete sustaining an acute injury, developing an overuse injury or becoming ill in a given sport?
* Within a given sport, what is the typical pattern and severity of injuries and illnesses?
* How do injury rates in various sports compare?
* Do participant characteristics and factors within competition and training affect risk?”

Question 29

Diagnostic Coding Systems for Sports Injuries

Answer 29

• Calgary Sports Medicine Diagnostic Coding System (SMDCS)
• Orchard Sports Injury & Illness Classification System (OSIICS)
• Initial codes = body area; further codes = injury type/pathology
• SMDCS employs a 6 digit code (00.00.00) following a systematic anatomical design
• First lists the anatomical area (00.) * Then tissue structure (.00.)
• Then diagnosis / type of injury (.00)
• Thigh, hamstring, muscle strain = TH.12.07

Question 30

Quantifying athlete exposure?

Answer 30

For injuries, exposure is generally quantified as the time during which athletes are at risk of injury (e.g. minutes played), distance covered, or a count of the number of specified events (e.g. tackles, throws or jumps).
* In some sports, exposure is commonly expressed as the number of athletic participations (e.g. games, races, training sessions), often referred to as ‘athletic exposures’.

Question 31

Incidence rate?

Answer 31

Provides a more precise estimate of the impact of exposure.
* Number of new cases that develop during a given time period divided by
the total person-time of observation.
* Includes both population at risk and each participant’s time at risk.
* Total person-time of observation is calculated by adding together all of the exposure time for each person.
* Most commonly expressed in team sports
* Injuries per 1000 player-hours
* Injuries per 1000 hours of training
* Injuries per 1000 hours of match-play * Injuries per 1000 athletic exposures (could be tackles in rugby for example)

Question 32

Quantifying injury severity?

Answer 32

No time loss = trivial

1-7 days = short-term = Mild

8-28 days = medium term = moerate

More than 28 days = long term = severe

Question 33

Quantifying Injury Burden

Answer 33

Injury burden combines incidence and time loss
* Burden = injury rate x injury severity
* Burden = total number of days lost per
1000 hours of exposure.

Question 34

Good study on injury incidence in 2016 euros:

Answer 34

Bahr et al. (2018)

Question 35

The Incidence Rate Ratio (IRR) is Used to Calculate Relative Risk of Injury:

Answer 35

1.0 = ncidence rate of an injury in the exposed group (e.g. FIFA 11+) is identical to the incidence rate of the unexposed group (Control group), indicating there is no association observed between the exposure to a risk factor or intervention and the development of a disease or injury.

> 1.0 = When the relative risk is greater than 1.0, a positive association exists between the exposure to a risk factor and a disease.

<1.0 =If the relative risk is less than 1.0, an inverse association exists, such that exposure to a particular variable (e.g. FIFA 11+) has a protective effect and decreases the risk of disease or injury to those exposed.

Question 36

How do you calculate incidence rate ratio?

Answer 36

(Intervention Incidence rate / control incidence rate) x 100 for a percentage

then 100 - answer to find out percentage difference

Question 37

Why are we focusing on research evidence?

Answer 37

To improve our knowledge and understanding of the extent of the sports injury problem, the causes of injury, the effectiveness of prevention measures, and the effectiveness of treatments.
* To ultimately inform and improve SEM practice.

Question 38

Evidence defintion?

Answer 38

One or more reasons for believing that something is or is not true.

Question 39

Evidence based defintion?

Answer 39

Supported by a large amount of scientific research.

Evidence based practice combines Patient concerns, Best research evidence and clinical expertise

Question 40

5 steps in evidence-based practice?

Answer 40

1
Asking focussed questions
2
Finding the evidence
3
Performing critical appraisal
4
Making a decision
5
Evaluating performance

Question 41

Do Injuries reduce performance?

Answer 41

Yes - has finical implications

Question 42

Lauren et al (2013) suggest what is the best injury prevention program?

Answer 42

Strength training and propriorecpetion training, this was supported by their 2018 study

Question 43

Biological perspective of ageing?

Answer 43

Cellular senescence - Reduced ability of isolated cells in culture to divide

organismal senecence - Declining ability to respond to stress including physiological challenges

Much age-related deterioration is the result of the effects of sedentary lifestyles and the development of medical conditions
rather than of ageing itself.

Question 44

What defines an older person?

Answer 44

Chronologicall age

Functional ability - Health-related attributes that enable older adults to be, and to do, what they value, which consists of an individual’s intrinsic capacity and their environment.

Healthy ageing - Process of developing and maintaining the functional ability that enables well- being in older age.
* The individual being able to do the things they value for as long as possible.

Question 45

Masters athlete definition?

Answer 45

Typically defined as older than 35 years who either trains for or takes part in athletic competitions often specifically designed for older participants.
*Many are experienced competitors who continue their athletic pursuits after their sports careers have ended, while others are individuals who return to sport after extended periods of inactivity or simply participate and train sporadically.

• Masters athletes are considered a paradigm of healthy ageing because they are able to maintain high levels of exercise at advanced ages and show remarkable physical/physiological function compared to their inactive peers.

Question 46

What happens after 30 years?

Answer 46

Skeletal muscle, strength and aerobic capacity all decline

With age muscle size and contraction velocity decrease, and fat increases

Question 47

What should you focus on training for the older athlete?

Answer 47

Power training, do things quickly as possible

Muscle power = force(invetiablly losing in age) x velocity (can increase this in older populations)

Question 48

Changes in body composition as you age?

Answer 48

Body mass
Steady increase during 30s, 40s & 50s * Stable until 70 y followed by decline

Body fat(%)
Steady increase during 30s, 40s, & 50s
* After age 70 y fat at all sites decreases
* Preferential accumulation in visceral
(intra-abdominal) region
* Accumulation of visceral fat linked to cardiovascular and metabolic disease

Fat free Mac (FFM, muscle mass):
Declines 2-3% per decade from 30-70 y
* Muscle mass loss accelerated after 65-70 y * Legs lose muscle faster

Reduction in fibre number and size:
Type II a/x > Type I
* Lipid & collagen content increase
* Specific force decreases (i.e. force/kg or
cm2) i.e. muscle quality
* Oxidative capacity decreases

Question 49

What’s saropenia?

Answer 49

A syndrome characterised by progressive and generalised loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life and death.

The primary problem in ageing sarcopenia appears to be a loss of alpha-motor neurones (type 2 = fast). As a result, almost half of the muscle fibres are lost from the age of 20 to the age of 80, at least in the vastus lateralis (thigh).