Methods matter: instrumental variable analysis may be a complementary approach to intention-to-treat analysis and as treated analysis when analysing data from sports injury trials

Running is acceptable and efficacious in adults with non-specific chronic low back pain: the ASTEROID randomised controlled trial

OBJECTIVES

Running is one of the most accessible forms of exercise, yet its suitability for adults with chronic low back pain (LBP) is unknown. This study assessed the efficacy and acceptability of running in adults with chronic LBP.

METHODS

This two-arm parallel (1:1) individually randomised controlled trial allocated 40 participants (mean (SD) age: 33 (6) years, female: 50%) with non-specific chronic LBP to a 12-week intervention or waitlist control. The intervention was a progressive run-walk interval programme comprising three 30-min sessions per week that were digitally delivered and remotely supported by an exercise physiologist. Efficacy outcomes were self-reported pain intensity (100-point visual analogue scale) and disability (Oswestry Disability Index). Acceptability outcomes were attrition, adherence and adverse events.

RESULTS

At 12-week follow-up, the intervention improved average pain intensity (mean net difference (95% CI): -15.30 (-25.33, -5.27) points, p=0.003), current pain intensity (-19.35 (-32.01, -6.69) points, p=0.003) and disability (-5.20 (-10.12, -0.24) points, P=0.038), compared with control. There was no attrition, and mean (SD) training adherence was 70% (20%; ie, 2.1 of 3 sessions per week). Nine non-serious adverse events deemed likely study-related were reported (lower limb injury/pain: n=7, syncope associated with an underlying condition: n=1, LBP: n=1).

CONCLUSIONS

A run-walk programme was considered an acceptable intervention by the participants to improve the pain intensity and disability in individuals aged 18-45 years with non-specific chronic LBP when compared with the control. An individualised and conservative run-walk programme should be considered a suitable form of physical activity for adults with chronic LBP.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry: ACTRN12622001276741. Registered on 29 September 2022.

Sport PRactice and its Effects on aortic size and valve function in bicuspid Aortic valve Disease: a cross-sectional report from the SPREAD study

OBJECTIVE

Concerns exist about the possible detrimental effects of exercise training on aortic size and valve function in individuals with bicuspid aortic valve (BAV). This multicentre international study aimed to determine the characteristics of aortic size and valve function in athletes versus non-athletes with BAV and athletes with tricuspid aortic valve (TAV).

METHODS

We enrolled competitive athletes with BAV and age- and sex-matched athletes with TAV and non-athletes with BAV. We assessed valve function, aortic size and biventricular measures using echocardiography. Individuals with established moderate-severe AV stenosis, regurgitation or significant aortic dilation were excluded from the study.

RESULTS

The study population comprised 504 participants: 186 competitive athletes with BAV (84% males; age 30±11 years), 193 competitive athletes with TAV and 125 non-athletes with BAV. The aortic annulus was greater in athletes with BAV than athletes with TAV and non-athletes with BAV (p<0.001). Both athletic and non-athletic individuals with BAV had greater sinuses of Valsalva, sino-tubular junction and ascending aorta diameters than athletes with TAV (p<0.001). However, no significant differences were found between athletes and non-athletes with BAV. Left ventricular index volumes and mass were greater in athletes with BAV than in the other two groups (p<0.001). Individuals with BAV (athletes and non-athletes) had greater mean gradients than TAV athletes.

CONCLUSION

This multicentre international study demonstrates no differences between athletes with BAV and non-athletes with BAV regarding aortic valve function or aortic dimensions. However, athletes with BAV have larger aortic diameters and a relatively worse valvular function than athletes with TAV.

Back pain Knowledge and beliefs Survey (BacKS): development and assessment of measurement properties

OBJECTIVE

To develop and evaluate a new patient-reported outcome measure (PROM) to assess people's knowledge and beliefs about low back pain.

METHODS

This study followed the COnsensus-based Standards for the selection of health Measurement INstruments guidelines. An 18-item preliminary version of the Back pain Knowledge and beliefs Survey (BacKS) was generated based on evidence-based key messages and current clinical guidelines for low back pain. Four items were added following input from three consumers and seven experts. Focus groups (n=9) confirmed content validity. The 22-item version was completed by 258 Australian-based adults (>18 years) with self-reported low back pain. A follow-up survey was sent 1 week later. The following measurement properties were evaluated to produce, and then assess the final version of BacKS: structural validity (exploratory factor analysis); internal consistency (Cronbach's alpha); test-retest reliability (intraclass correlation coefficient); measurement error (Smallest Detectable Change); construct validity (hypothesis tested: moderate positive Pearson correlation between BacKS and Back Beliefs Questionnaire); plus, interpretability and feasibility.

RESULTS

The final BacKS comprised 20 items with a 2-factor structure (biomedical factor: 9 items, score ranging from 9 to 45, and self-care factor: 11 items, score ranging from 11 to 55). Internal consistency and reliability were adequate (>0.70) for each factor. Smallest detectable change was 4.4 (biomedical factor) and 7.0 (self-care factor). Our construct validity hypothesis was confirmed (Pearson correlation=0.53). No floor or ceiling effects were detected.

CONCLUSION

The BacKS is a valid, reliable and feasible PROM to measure knowledge and beliefs about low back pain in clinical practice and research settings.

Ankle-GO score is associated with the probability of becoming coper after lateral ankle sprain: a 1-year prospective cohort study

OBJECTIVE

To analyse the association between Ankle-GO score during the return to sport process and the probability of becoming a coper 1 year after lateral ankle sprain (LAS). Copers were defined as patients returning to their preinjury sport without loss of function and reporting no episodes of reinjury or giving-way.

METHODS

Two months after a LAS, patients performed the Ankle-GO assessment which includes a cluster of four functional tests and two self-reported questionnaires for a maximum score of 25 points. One year after injury, participants were classified as copers or non-copers. Eight potential predictive variables associated with coper status were compared between the groups. Receiver operating characteristic curves (area under the curve (AUC)) and multivariable logistic regression models with OR and 95% CIs were used to determine the association of potential factors, including the Ankle-GO score, with copers.

RESULTS

64 patients (56% females; age 33.7±13.2 years) completed the Ankle-GO-GO at 2 months postinjury. At 1 year postinjury, 10 patients (15%) were lost to follow-up, and only 17 of 54 patients (31%) became copers. Two-month Ankle-GO score was higher among copers (9.9±4.9 points vs 6.9±3.7, p=0.015) and was associated with future coper status at 1 year (AUC=0.70). Patients with an Ankle-GO score above 11 points and male patients were more likely to become copers (OR=12.1; 95% CI 2.5 to 59, p=0.002 and OR=5.2; 95% CI 1.2 to 22.4, p=0.026, respectively).

CONCLUSION

The Ankle-GO may help identify patients more likely to become copers within a year of injury. Those with low Ankle-GO scores and female patients should receive additional rehabilitation to increase the odds of becoming a coper.

Efficacy of the FIFA cooling break heat policy during an intermittent treadmill football simulation in hot conditions in trained males

OBJECTIVE

To evaluate the efficacy of the Fédération Internationale de Football Association (FIFA) cooling break policy against alternative cooling configurations in attenuating thermal strain during simulated football in the heat.

METHODS

12 males (age: 27±6 years, V̇O2peak: 61±7 mL/kg/min) completed five 90 min intermittent treadmill football match simulations in 40°C and 41% relative humidity (32°C wet-bulb globe temperature) with different cooling configurations: regular match without cooling breaks (REG), 3 min breaks without cooling (BRKno-cool), 3 min breaks with cooling (BRKcool: current FIFA policy; chilled fluid ingestion and ice towel across neck and shoulders), 5 min extended half-time without cooling breaks (ExtHTonly) and 3 min cooling breaks with 5 min ExtHT (ExtHTcool). Rectal temperature (Tre), heart rate, whole-body sweat rate (WBSR) and rating of perceived exertion (RPE) were recorded. Data are presented as mean (95% CIs).

RESULTS

Final Tre was lower in BRKno-cool (0.20°C (0.01, 0.39), p=0.038), BRKcool (0.39°C (0.21, 0.57), p<0.001) and ExtHTcool (0.40°C (0.22, 0.58), p<0.001) than REG (39.1°C (38.8, 39.3)). Mean Tre was lower in ExtHTcool (38.2°C (38.0, 38.4)) than BRKcool (38.3°C (38.1, 38.5), p=0.018), BRKno-cool and ExtHTonly (38.4°C (38.2, 38.6), p<0.001) and REG (38.5°C (38.3, 38.7), p<0.001). Mean heart rate was lower during BRKcool (6 beats/min (4, 7), p<0.001) and ExtHTcool (7 beats/min (6, 8), p<0.001) compared with REG. WBSR was comparable across trials (p≥0.07) and RPE was attenuated during BRKcool (0.4 (0.1, 0.7), p=0.004) and ExtHTcool (0.5 (0.2, 0.7), p=0.002), compared with REG.

CONCLUSION

BRKcool and ExtHTcool attenuated thermal, cardiovascular and perceptual strain during a simulated football match in the heat. Additional strategies may be required in field settings or under harsher conditions.

High rates of respiratory illnesses upon arrival: lessons from Team USA at the Santiago 2023 Pan American and Parapan American Games

OBJECTIVE

To describe the incidence and characteristics of injuries and illnesses among Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG), with a particular focus on the incidence of respiratory illnesses and on injuries for sports new to the Olympic and Paralympic programmes.

METHODS

Illnesses and injuries occurring among the 870 Team USA athletes competing in the Santiago 2023 PAG or PPAG were documented within Team USA's Injury and Illness Surveillance system. Illness and injury incidence per 1000 athlete-days (ADs) and incidence ratios (IR) were calculated, both with 95% CIs.

RESULTS

Illness (IR 2.5, 95% CI 1.6, 3.9) and injury (IR 1.8, 95% CI 1.3, 2.5) rates were greater during PPAG compared with PAG. Illness rates were higher in the pre-opening ceremony period compared with the competition period for both PAG (IR 2.7, 95% CI 1.1, 5.9) and PPAG (IR 1.9, 95% CI 0.9, 3.8). Respiratory illness was the most common illness with 3.2% and 8.9% of all Team USA athletes reporting a respiratory illness during the PAG and PPAG, respectively. Sports that are relatively new to the Olympic/Paralympic programmes exhibited the highest injury rates during the Games: breaking (250.0 (91.7, 544.2) per 1000 ADs), Para taekwondo (93.8 (19.3, 274.0) per 1000 ADs) and surfing (88.9 (24.2, 227.6) per 1000 ADs).

CONCLUSION

Respiratory illness rates were the most common type of illness during both PAG and PPAG and were more likely to occur prior to competition starting. Our data have identified high injury risk populations (breaking, surfing, Para taekwondo) and timing (pre-opening ceremony period) for further risk factor analysis.

Differences in the technical performance of heading between men and women football players during FIFA World Cup 2022 and FIFA Women's World Cup 2023 matches

Objectives

To compare the incidence of headers, attempted headers, and other head impacts, and the difference in heading descriptors, including technical performance, between men and women in a purposive sample of FIFA World Cup 2022 (FWC22) and FIFA Women's World Cup (FWWC23) matches.

Methods

Video analysis of all observed headers, attempted headers and other head impacts during eight FWC matches (FWC22 (n=4); FWWC23 (n=4)) where the same national teams competed. Heading descriptors (including ball delivery method, purpose of the header and involvement of other players) and technical performance of each header (including controlled or uncontrolled header, use of upper body, point of head contact) were analysed using negative binomial regression analyses with men as the reference group (reported as incidence rate ratios (IRR)). Timing of eye closure was analysed using a t-test; α-error, p=<0.05.

Results

From 973 head impacts, 845 (87%) were headers (FWC22 mean 5.0 headers/player/match, FWWC23 mean 4.6 headers/player/match), 93 (10%) were attempted headers and 35 (4%) were unintentional head impacts. When compared with men, women were less likely to perform controlled headers (73% vs 83%, IRR 1.20, p=0.01), use their foreheads (IRR 2.36, p=<0.001) and their upper body during the header (80% vs 88%, IRR 1.29, p=0.005). Women also closed their eyes earlier before the header (1.91 vs 1.56 frames, d=0.41, p=0.002).

Conclusion

There were significant differences in heading technique between women and men, which could be important to address in training to improve heading performance and potentially reduce short-term and long-term burden of heading.

Prevalence of electrocardiographic markers associated with myocardial fibrosis in masters athletes: a cohort study

Objectives

Myocardial fibrosis (MF) is associated with an increased predisposition to adverse cardiac events. The accumulation of high-volume and high-intensity exercise over an extended duration potentially increases the risk of MF. Specific electrocardiographic markers have been correlated with the presence of MF. This study assessed the prevalence of MF-related electrocardiographic markers in a Track and Field Master Athletics Cohort (TaFMAC).

Methods

Twelve-lead resting electrocardiograms (ECGs) were conducted on 155 athletes (90 males and 65 females) participating in the World Masters Athletics 2022. The ECG markers associated with MF, including pathological Q waves, inverted T waves, fragmented QRS complex, and prolonged QRS complex, were compared among different athletic specialities (endurance athletes n=51, sprinters n=69 and strength and power n=35).

Results

Overall, 71 instances of MF-related markers were identified from 155 ECG recordings (46%). Fragmented QRS emerged as the most common marker, with a prevalence of 29% in endurance and strength and power athletes, and 35% in sprinters. No significant group differences were observed in the prevalence of MF markers, whether analysed collectively (p=0.467) or individually (pathological Q waves p=0.367, inverted T waves p=0.309, fragmented QRS complex p=0.747 and prolonged QRS complex p=0.132).

Conclusions

The prevalence of MF markers, as determined by resting ECG, was evident in nearly half of masters athletes, irrespective of sex and sporting specialisation. These findings suggest resting ECG as a promising non-invasive method for the early identification of MF in athlete's hearts.

How can we better engage female athletes? A novel approach to health and performance education in adolescent athletes

Objectives

To evaluate the impact of a video series versus online pamphlets/blog posts on Female Athlete Triad (Triad) and Relative Energy Deficiency in Sport (REDs) knowledge in high school female runners.

Methods

Runners from 10 US schools were cluster-randomised into groups to either watch videos or read pamphlets on Triad/REDs, nutrition, menstrual cycle, bone health and mental health. Changes in knowledge and interest were assessed using generalised estimating equations.

Results

Forty-five runners were in the video intervention group (mean age=16.0) and 39 in the control (mean age=15.7). Both groups showed knowledge gains for all topics, except for mental health, where knowledge was already high. The intervention group's knowledge increase (means=75.7 and 93.3) was not significantly higher than the control's (means=77.9 and 93.6) (p=0.149). However, the intervention group had stronger scores on behavioural impact, information novelty and interest (means=3.77, 3.93 and 4.14) compared with the control's (means=3.36, 3.48 and 3.52) (p≤0.05, p≤0.05 and p≤0.001).

Conclusion

Both videos and pamphlets improved knowledge of Triad/REDs and female athlete science, however videos had a greater influence on athletes' engagement and behavioural intentions.

Longitudinal change in cardiorespiratory fitness and the association with cardiovascular disease and all-cause mortality in young Asian men: a cohort study

Introduction

Cardiorespiratory fitness (CRF) in young adulthood is a determinant of chronic disease risk. To better understand whether CRF might also behave as a modifiable risk factor, we examined the associations between longitudinal changes in 2.4 km run times and health outcomes in a cohort of healthy young men.

Methods

Our dataset comprised individual run times and health outcomes captured in four national registries. Cox proportional hazards models were used to examine the association between baseline run times and relative hazards of first major adverse cardiovascular events (MACE) and all-cause mortality (ACM). Relative hazards associated with longitudinal change in run times were estimated using models that were adjusted for run-time at baseline.

Results

The study sample comprised 148 825 healthy men ages 18-34 years who had undergone at least two routine fitness tests that were 5-9 years apart. During 1 294 778 person-years of follow-up, we observed 1275 first MACE and 764 ACM events occurring at mean ages of 43.2 (SD 6.0) years and 39.2 (SD 6.6) years, respectively. A 1% increase in run-time per annum was associated with a 1.13 (95% CI 1.10 to 1.16) times greater hazard of first MACE and a 1.06 (95% CI 1.02 to 1.10) times greater hazard of ACM. The association between longitudinal change in run times and first MACE was preserved in sensitivity analyses using models adjusted for body mass index at baseline.

Conclusion

Among men under the age of 35 years, longitudinal change in run times was associated with the risk of cardiovascular disease two decades onwards.

Is radial extracorporeal shock wave therapy (rESWT), sham-rESWT or a standardised exercise programme in combination with advice plus customised foot orthoses more effective than advice plus customised foot orthoses alone in the treatment of plantar fasciopathy? A double-blind, randomised, sham-controlled trial

OBJECTIVES

To assess whether radial extracorporeal shock wave therapy (rESWT), sham-rESWT or a standardised exercise programme in combination with advice plus customised foot orthoses is more effective than advice plus customised foot orthoses alone in alleviating heel pain in patients with plantar fasciopathy.

METHODS

200 patients with plantar fasciopathy were included in a four-arm, parallel-group, sham-controlled, observer-blinded, partly patient-blinded trial. At baseline, before randomisation, all patients received advice plus customised foot orthoses. Patients were randomised to rESWT (n=50), sham-rESWT (n=50), exercise (n=50) or advice plus customised foot orthoses alone (n=50). Patients in the rESWT and sham-rESWT groups received three treatments. The exercise programme comprised two exercises performed three times a week for 12 weeks, including eight supervised sessions with a physiotherapist. Patients allocated to advice plus customised foot orthoses did not receive additional treatment. The primary outcome was change in heel pain during activity in the previous week per Numeric Rating Scale (0-10) from baseline to 6-month follow-up. The outcome was collected at baseline, and 3, 6 and 12 months.

RESULTS

The primary analysis showed no statistically significant between-group differences in mean change in heel pain during activity for rESWT versus advice plus customised foot orthoses (-0.02, 95% CI -1.01 to 0.96), sham-rESWT versus advice plus customised foot orthoses (0.52, 95% CI -0.49 to 1.53) and exercise versus advice plus customised foot orthoses (-0.11, 95% CI -1.11 to 0.89) at 6 months.

CONCLUSION

In patients with plantar fasciopathy, there was no additional benefit of rESWT, sham-rESWT or a standardised exercise programme over advice plus customised foot orthoses in alleviating heel pain.

TRIAL REGISTRATION NUMBER

NCT03472989.

Descriptive epidemiology study of hand injuries sustained in Gaelic football referred to a hand therapy service over 1 year

Objectives

Gaelic football requires ball handling, such as bouncing, fist passing and catching. To date, no research has examined the types of injuries sustained to the hand in this sport. This study aims to establish the types of orthopaedic hand injuries sustained in Gaelic football.

Methods

This was a retrospective descriptive epidemiology study of Gaelic football-related hand injuries treated at a hand therapy unit. The nature of injuries was categorised along with collated variables on player demographics and injury profiles. Potential correlations between injury and continuous demographic data were analysed using the Mann-Whitney U and Kruskal-Wallis tests. Pearson's χ2 test was used for categorical data (p<0.05).

Results

287 referrals were identified. Most players were men (n=189; 65.9%), and the average age was 17 (IQR 14-25). Most fractures were to the volar base of the middle phalanx (n=110; 42.8%). Significant differences were found between the age of male and female players with fractures under 18 (p<0.05), the distribution of left and right-hand fractures by age (p<0.05), the distribution of fractures by bone type (p<0.05) and also between sex and affected ray (p<0.05), bone type (p<0.05) and mechanism of injury (p=0.05).

Conclusion

This study established the types of musculoskeletal hand injuries sustained by players in Gaelic football. Considering developmental, anthropometric and rule differences between male and female players across the age range may explain variations in injuries. This data can help devise injury prevention and management strategies for Gaelic football.

Hip and core exercise programme prevents running-related overuse injuries in adult novice recreational runners: a three-arm randomised controlled trial (Run RCT)

OBJECTIVE

This study aims to investigate the efficacy of two exercise interventions in reducing lower extremity (LE) injuries in novice recreational runners.

METHODS

Novice runners (245 female, 80 male) were randomised into hip and core (n=108), ankle and foot (n=111) or control (n=106) groups. Interventions were completed before running and included exercise programmes focusing on either (1) hip and core or (2) ankle and foot muscles. The control group performed static stretching exercises. All groups were supervised by a physiotherapist and performed the same running programme. Injuries and running exposure were registered using weekly questionnaires during the 24-week study. Primary outcome was running-related LE injury.

RESULTS

The incidence of LE injuries was lower in the hip and core group compared with the control group (HR 0.66; 95% CI 0.45 to 0.97). The average weekly prevalence of overuse injuries was 39% lower (prevalence rate ratio, PRR 0.61, 95% CI 0.39 to 0.96), and the prevalence of substantial overuse injuries was 52% lower (PRR 0.48, 95% CI 0.27 to 0.90) in the hip and core group compared with the control group. No significant difference was observed between the ankle and foot group and control group in the prevalence of overuse injuries. A higher incidence of acute injuries was observed in the ankle and foot group compared with the control group (HR 3.60, 95% CI 1.20 to 10.86).

CONCLUSION

A physiotherapist-guided hip and core-focused exercise programme was effective in preventing LE injuries in novice recreational runners. The ankle and foot programme did not reduce LE injuries and did not protect against acute LE injuries when compared with static stretching.

Imaging associations enhance the understanding of ECG abnormalities in male Brazilian football players: findings from the B-Pro Foot ECG study

OBJECTIVES

To evaluate the prevalence of abnormal ECG findings and their association with imaging results in male Brazilian football players.

METHODS

The 'B-Pro Foot ECG' is a multicentre observational study conducted in 82 Brazilian professional clubs. It analysed 6125 players aged 15-35 years (2496 white, 2004 mixed-race and 1625 black individuals) who underwent cardiovascular screening from 2002 to 2023. All ECGs were reviewed by two experienced cardiologists in the athlete's care. Those with abnormal findings underwent further investigations, including a transthoracic echocardiogram (TTE). Cardiac magnetic resonance (CMR) was subsequently performed based on TTE findings or clinical suspicion.

RESULTS

In total, 180 (3%) players had abnormal ECGs and 176 (98%) showed normal TTE results. Athletes aged 26-35 years had a higher prevalence of abnormal ECGs than younger athletes (15-25 years). Black players had a higher prevalence of T-wave inversion (TWI) in the inferior leads than white players (2.6% vs 1.4%; p=0.005), as well as in V5 (2.9%) and V6 (2.1%) compared with white (1.2% and 1.0%; p<0.001) and mixed-race (1.5% and 1.2%; p<0.05) players, respectively. TTE parameters were similar across ethnicities. However, four out of 75 players with inferolateral TWI showed abnormal TTEs and CMR findings consistent with cardiomyopathies. CMR also showed cardiomyopathies or myocarditis in four players with inferolateral TWI and normal TTEs. In total, nine (0.1%) athletes were diagnosed with cardiac diseases and were followed for 40±30 months, with no cardiac events documented.

CONCLUSION

This study found a 3% prevalence of abnormal ECGs in male Brazilian football players. Inferolateral TWI was associated with cardiac pathologies confirmed by CMR, even in athletes with a normal TTE.

Low socioeconomic status is associated with worse treatment outcomes in patients with Achilles tendinopathy

OBJECTIVE

To assess whether there is a difference in symptom severity at baseline and 24 weeks follow-up between conservatively managed patients with Achilles tendinopathy (AT) with low socioeconomic status (SES) compared with those with high SES.

METHODS

In this prospective cohort study, 200 patients with AT were included and treated according to current guidelines. We linked a neighbourhood SES indicator based on income, employment and education level and divided the patient population into quintiles, with Q1 being the highest SES and Q5 the lowest. Symptom severity at baseline and follow-up was assessed using the Victorian Institute of Sports Assessment-Achilles (VISA-A) score. Treatment adherence was not measured. We used a general linear model and the mean VISA-A scores at baseline and at 6, 12 and 24 weeks follow-up were compared between Q1 (n=45) and Q5 (n=39), while adjusting for age, sex, body mass index (BMI), Ankle Activity Score, symptom duration and baseline VISA-A score.

RESULTS

Patients had a median age of 51 years and median BMI of 25.4, 40% were female. 74%, 70% and 58% of the participants completed the VISA-A at 6, 12 and 24 weeks, respectively. VISA-A scores at baseline were similar for Q1 and Q5 (43.9 and 41.8, p=0.591). At 24 weeks, there was a mean (95% CI) difference of 11.2 (1.0 to 21.3, p=0.032) points in favour of Q1 on the VISA-A score.

CONCLUSION

AT patients with low SES may have worse outcomes when treated using the current guidelines. The difference in VISA-A score at 24 weeks is larger than the minimal clinically important difference and might be clinically relevant, but comes with uncertainty due to the large dispersion in the data. Clinicians need to consider the impact of social inequality when developing and implementing treatment plans.

Strength, power and aerobic capacity of transgender athletes: a cross-sectional study

OBJECTIVE

The primary objective of this cross-sectional study was to compare standard laboratory performance metrics of transgender athletes to cisgender athletes.

METHODS

19 cisgender men (CM) (mean±SD, age: 37±9 years), 12 transgender men (TM) (age: 34±7 years), 23 transgender women (TW) (age: 34±10 years) and 21 cisgender women (CW) (age: 30±9 years) underwent a series of standard laboratory performance tests, including body composition, lung function, cardiopulmonary exercise testing, strength and lower body power. Haemoglobin concentration in capillary blood and testosterone and oestradiol in serum were also measured.

RESULTS

In this cohort of athletes, TW had similar testosterone concentration (TW 0.7±0.5 nmol/L, CW 0.9±0.4 nmol/), higher oestrogen (TW 742.4±801.9 pmol/L, CW 336.0±266.3 pmol/L, p=0.045), higher absolute handgrip strength (TW 40.7±6.8 kg, CW 34.2±3.7 kg, p=0.01), lower forced expiratory volume in 1 s:forced vital capacity ratio (TW 0.83±0.07, CW 0.88±0.04, p=0.04), lower relative jump height (TW 0.7±0.2 cm/kg; CW 1.0±0.2 cm/kg, p<0.001) and lower relative V̇O2max (TW 45.1±13.3 mL/kg/min/, CW 54.1±6.0 mL/kg/min, p<0.001) compared with CW athletes. TM had similar testosterone concentration (TM 20.5±5.8 nmol/L, CM 24.8±12.3 nmol/L), lower absolute hand grip strength (TM 38.8±7.5 kg, CM 45.7±6.9 kg, p=0.03) and lower absolute V̇O2max (TM 3635±644 mL/min, CM 4467±641 mL/min p=0.002) than CM.

CONCLUSION

While longitudinal transitioning studies of transgender athletes are urgently needed, these results should caution against precautionary bans and sport eligibility exclusions that are not based on sport-specific (or sport-relevant) research.

Association between change in cardiorespiratory fitness and prostate cancer incidence and mortality in 57 652 Swedish men

OBJECTIVES

To examine the associations between changes in cardiorespiratory fitness (CRF) in adulthood and prostate cancer incidence and mortality.

METHODS

In this prospective study, men who completed an occupational health profile assessment including at least two valid submaximal CRF tests, performed on a cycle ergometer, were included in the study. Data on prostate cancer incidence and mortality were derived from national registers. HRs and CIs were calculated using Cox proportional hazard regression with inverse probability treatment weights of time-varying covariates.

RESULTS

During a mean follow-up time of 6.7 years (SD 4.9), 592 (1%) of the 57 652 men were diagnosed with prostate cancer, and 46 (0.08%) died with prostate cancer as the primary cause of death. An increase in absolute CRF (as % of L/min) was associated with a reduced risk of prostate cancer incidence (HR 0.98, 95% CI 0.96 to 0.99) but not mortality, in the fully adjusted model. When participants were grouped as having increased (+3%), stable (±3%) or decreased (-3%) CRF, those with increased fitness also had a reduced risk of prostate cancer incidence compared with those with decreased fitness (HR 0.65, 95% CI 0.49 to 0.86), in the fully adjusted model.

CONCLUSION

In this study of employed Swedish men, change in CRF was inversely associated with risk of prostate cancer incidence, but not mortality. Change in CRF appears to be important for reducing the risk of prostate cancer.

Causes of sudden cardiac arrest and death and the diagnostic yield of sport preparticipation screening in children

OBJECTIVE

Evidence on the increased risk of sports-related sudden cardiac arrest and death (SCA/D) and the potential benefit of cardiovascular preparticipation screening (PPS) in children is limited. We assessed the burden and circumstances of SCA/D and the diagnostic yield of cardiovascular PPS in children aged 8-15 years.

METHODS

Data on the incidence and causes of SCA/D from 2011 to 2020 were obtained from the Veneto region (Italy) sudden death registry, hospital records and local press. During the same period, we assessed the results of annual PPS in 25 251 young competitive athletes aged 8-15 years who underwent 58 185 evaluations (mean 2.3/athlete) in Padua, Italy.

RESULTS

Over 10 years, 26 SCA/D occurred in children aged 8-15 years in the Veneto region: 6 in athletes (incidence 0.7/100 000/year, all ≥12 years) versus 20 in non-athletes (0.7/100 000/year, 17/20 ≥12 years). In total, 4/6 athletes versus 1/20 non-athletes survived. The cause of SCA/D remained unexplained in four athletes and in nine non-athletes. No athlete suffered SCA/D from structural diseases potentially identifiable by PPS. The incidence of SCA/D in athletes and non-athletes was 0.2/100 000/year in the 8-11 years group versus 1.3/100 000/year in the 12-15 years group. PPS identified 26 new diagnoses of cardiovascular diseases (CVDs) at risk of SCA/D, more often in children ≥12 years old (0.06%/evaluation) than <12 years old (0.02%/evaluation, p=0.02). Among athletes with a negative PPS, two suffered unexplained SCA/D during follow-up, one during exercise.

CONCLUSIONS

In children aged 8-15 years, the incidence of SCA/D and the yield of PPS for identifying at-risk CVD were both substantially higher in those ≥12 years, suggesting that systematic PPS may be more useful beyond this age.

Do the associations of daily steps with mortality and incident cardiovascular disease differ by sedentary time levels? A device-based cohort study

OBJECTIVES

This study aims to examine the associations of daily step count with all-cause mortality and incident cardiovascular disease (CVD) by sedentary time levels and to determine if the minimal and optimal number of daily steps is modified by high sedentary time.

METHODS

Using data from the UK Biobank, this was a prospective dose-response analysis of total daily steps across low (<10.5 hours/day) and high (≥10.5 hours/day) sedentary time (as defined by the inflection point of the adjusted absolute risk of sedentary time with the two outcomes). Mortality and incident CVD was ascertained through 31 October 2021.

RESULTS

Among 72 174 participants (age=61.1±7.8 years), 1633 deaths and 6190 CVD events occurred over 6.9 (±0.8) years of follow-up. Compared with the referent 2200 steps/day (5th percentile), the optimal dose (nadir of the curve) for all-cause mortality ranged between 9000 and 10 500 steps/day for high (HR (95% CI)=0.61 (0.51 to 0.73)) and low (0.69 (0.52 to 0.92)) sedentary time. For incident CVD, there was a subtle gradient of association by sedentary time level with the lowest risk observed at approximately 9700 steps/day for high (0.79 (0.72 to 0.86)) and low (0.71 (0.61 to 0.83)) sedentary time. The minimal dose (steps/day associated with 50% of the optimal dose) of daily steps was between 4000 and 4500 steps/day across sedentary time groups for all-cause mortality and incident CVD.

CONCLUSIONS

Any amount of daily steps above the referent 2200 steps/day was associated with lower mortality and incident CVD risk, for low and high sedentary time. Accruing 9000-10 500 steps/day was associated with the lowest mortality risk independent of sedentary time. For a roughly equivalent number of steps/day, the risk of incident CVD was lower for low sedentary time compared with high sedentary time.

Lack of leisure time physical activity and variations in cardiovascular mortality across US communities: a comprehensive county-level analysis (2011-2019)

OBJECTIVES

To investigate the associations between county-level proportions of adults not engaging in leisure-time physical activity (no LTPA) and age-adjusted cardiovascular mortality (AACVM) rates in the overall US population and across demographics.

METHODS

Analysing 2900 US counties from 2011 to 2019, we used the Centers for Disease Control and Prevention (CDC) databases to obtain annual AACVM rates. No LTPA data were sourced from the CDC's Behavioural Risk Factor Surveillance System survey and county-specific rates were calculated using a validated multilevel regression and poststratification modelling approach. Multiple regression models assessed associations with county characteristics such as socioeconomic, environmental, clinical and healthcare access factors. Poisson generalised linear mixed models were employed to calculate incidence rate ratios (IRR) and additional yearly deaths (AYD) per 100 000 persons.

RESULTS

Of 309.9 million residents in 2900 counties in 2011, 7.38 million (2.4%) cardiovascular deaths occurred by 2019. County attributes such as socioeconomic, environmental and clinical factors accounted for up to 65% (adjusted R2=0.65) of variance in no LTPA rates. No LTPA rates associated with higher AACVM across demographics, notably among middle-aged adults (standardised IRR: 1.06; 95% CI (1.04 to 1.07)), particularly women (1.09; 95% CI (1.07 to 1.12)). The highest AYDs were among elderly non-Hispanic black individuals (AYD=68/100 000).

CONCLUSIONS

Our study reveals a robust association between the high prevalence of no LTPA and elevated AACVM rates beyond other social determinants. The most at-risk groups were middle-aged women and elderly non-Hispanic black individuals. Further, county-level characteristics accounted for substantial variance in community LTPA rates. These results emphasise the need for targeted public health measures to boost physical activity, especially in high-risk communities, to reduce AACVM.

Joint associations of device-measured physical activity and abdominal obesity with incident cardiovascular disease: a prospective cohort study

OBJECTIVE

To examine the joint associations between physical activity and abdominal obesity with the risk of cardiovascular disease (CVD) events.

METHODS

We included 70 830 UK Biobank participants (mean age±SD=61.6 ± 7.9 years; 56.4% women) with physical activity measured by wrist-worn accelerometers and without major chronic diseases. Participants were jointly categorised into six groups based on their physical activity level (tertiles of total volume and specific intensity levels) and presence or absence of abdominal obesity based on measured waist circumference. Associations with incident CVD (fatal and non-fatal events) were determined using proportional subdistribution hazard models with multivariable adjustment.

RESULTS

After excluding events during the first 2 years of follow-up, participants were followed for a median of 6.8 years, during which 2795 CVD events were recorded. Compared with the low abdominal adiposity and highest tertile of physical activity, abdominal obesity was associated with higher risk of incident CVD, especially in those with low levels of vigorous-intensity physical activity (HR 1.42, 95% CI 1.22 to 1.64). Approximately 500 min per week of moderate-to-vigorous intensity and approximately 30-35 min of vigorous-intensity physical activity offset the association of abdominal obesity and the risk of having a CVD event.

CONCLUSION

Physical activity equivalent to approximately 30-35 min of vigorous intensity per week appears to offset the association between abdominal obesity and incident CVD. About 15 times more physical activity of at least moderate intensity is needed to achieve similar results.

If we build it together, will they use it? A mixed-methods study evaluating the implementation of Prep-to-Play PRO: an injury prevention programme for women's elite Australian Football

OBJECTIVES

We evaluated the implementation of Prep-to-Play PRO, an injury prevention programme for women's elite Australian Football League (AFLW).

METHODS

The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) of Prep-to-Play PRO were assessed based on the proportion of AFLW players and/or staff who: were aware of the programme (R), believed it may reduce anterior cruciate ligament injury (E), attempted to implement any/all programme components (A), implemented all intended components as practically as possible (I) and intended future programme implementation (M). Quantitative and qualitative data were triangulated to assess 58 RE-AIM items (evidence of yes/no/unsure/no evidence) and the 5 RE-AIM dimensions (fully achieved=evidence of yes on >50% dimension items, partially achieved=50% of items evidence of yes and 50% unsure or 50% mix of unsure and unanswered, or not met=evidence of yes on <50% dimension items).

RESULTS

Multiple sources including AFLW training observations (n=7 total), post-implementation surveys (141 players, 25 staff), semistructured interviews (19 players, 13 staff) and internal programme records (9 staff) contributed to the RE-AIM assessment. After the 2019 season, 8 of 10 (80%) AFLW clubs fully met all five RE-AIM dimensions. All 10 clubs participating in the AFLW fully achieved the reach (R) dimension. One club partially achieved the implementation (I) dimension, and one club partially achieved the effectiveness (E) and adoption (A) dimensions.

CONCLUSION

The Prep-to-Play PRO injury prevention programme for the AFLW achieved high implementation, possibly due to the programme's deliberately flexible approach coupled with our pragmatic definition of implementation. Engaging key stakeholders at multiple ecological levels (organisation, coaches, athletes) throughout programme development and implementation likely enhanced programme implementation.

UEFA Women's Elite Club Injury Study: a prospective study on 1527 injuries over four consecutive seasons 2018/2019 to 2021/2022 reveals thigh muscle injuries to be most common and ACL injuries most burdensome

OBJECTIVE

Injuries in women's football (soccer) have scarcely been investigated, and no study has been conducted in the highest competitive level involving club teams from different countries. Our aim was to investigate the time-loss injury epidemiology and characteristics among women's elite football players over four seasons.

METHODS

596 players from 15 elite women's teams in Europe were studied prospectively during the 2018/2019 to 2021/2022 seasons (44 team seasons). Medical staff recorded individual player exposure and time-loss injuries. Injury incidence was calculated as the number of injuries per 1000 playing hours and injury burden as the number of days lost per 1000 hours.

RESULTS

1527 injuries were recorded in 463 players with an injury incidence of 6.7 (95% CI 6.4 to 7.0) injuries per 1000 hours and a nearly fourfold higher incidence during match play compared with training (18.4, 95% CI 16.9 to 19.9 vs 4.8, 95% CI 4.5 to 5.1; rate ratio 3.8, 95% CI 3.5 to 4.2). Thigh muscle injuries (hamstrings 12%, 188/1527, and quadriceps 11%, 171/1527) were the most frequent injury, while anterior cruciate ligament (ACL) injury had the highest burden (38.0 days lost per 1000 hours, IQR 29.2-52.1) with median days lost of 292 (IQR 246-334) days. Concussions constituted 3% (47/1527) of all injuries, with more than half of them (55%, 26/47) due to ball-related impact.

CONCLUSION

An elite women's football team can expect approximately 35 time-loss injuries per season. Thigh muscle injury was the most common injury and ACL injury had the highest injury burden.

Leisure time physical activity is associated with improved diastolic heart function and is partly mediated by unsupervised quantified metabolic health

Objectives

To investigate the association between leisure time physical activity (LTPA) and MRI-based diastolic function and the mediating role of metabolic health.

Methods

This cross-sectional analysis comprised 901 participants (46% women, mean age (SD): 56 (6) years (The Netherlands, 2008-2012)). LTPA was assessed via questionnaire, quantified in metabolic equivalent of tasks (METs)-minutes per week and participants underwent abdominal and cardiovascular MRI. Confirmatory factor analysis was used to construct the metabolic load factor. Piecewise structural equation model with adjustments for confounders was used to determine associations between LTPA and diastolic function and the mediating effect of metabolic load.

Results

Significant differences in mitral early/late peak filling rate (E/A) ratio per SD of LTPA (men=1999, women=1870 MET-min/week) of 0.18, (95% CI= 0.03 to 0.33, p=0.021) were observed in men, but not in women: -0.01 (-0.01 to 0.34, p=0.058). Difference in deceleration time of mitral early filling (E-DT) was 0.13 (0.01 to 0.24, p=0.030) in men and 0.17 (0.05 to 0.28, p=0.005) in women. Metabolic load, including MRI-based visceral and subcutaneous adipose tissue, fasting glucose, high-density lipoprotein cholesterol and triglycerides, mediated these associations as follows: E/A-ratio of 0.030 (0.000 to 0.067, 19% mediated, p=0.047) in men but not in women: 0.058 (0.027 to 0.089, p<0.001) and E-DT not in men 0.004 (-0.012 to 0.021, p=0.602) but did in women 0.044 (0.013 to 0.057, 27% mediated, p=0.006).

Conclusions

A larger amount of LTPA was associated with improved diastolic function where confirmatory factor analysis-based metabolic load partly mediated this effect. Future studies should assess whether improving indicators of metabolic load alongside LTPA will benefit healthy diastolic function even more.

A new measure of exercise adherence: the ATEMPT (Adherence To Exercise for Musculoskeletal Pain Tool)

OBJECTIVES

This study aimed to (1) develop a new measure of adherence to exercise for musculoskeletal (MSK) pain (Adherence To Exercise for Musculoskeletal Pain Tool: ATEMPT) based on previously conceptualised domains of exercise adherence, (2) report the content and structural validity, internal consistency, test-retest reliability, and measurement error for the ATEMPT outcome measure in patients managed with exercise for MSK pain.

METHODS

ATEMPT was created using statements describing adherence generated by patients, physiotherapists and researchers, with content validity established. Baseline and retest questionnaires were distributed to patients recommended exercise for MSK pain in 11 National Health Service physiotherapy clinics. Items demonstrating low response variation were removed and the following measurement properties assessed: structural validity, internal consistency, test-retest reliability and measurement error.

RESULTS

Baseline and retest data were collected from 382 and 112 patients with MSK pain, respectively. Confirmatory factor analysis established that a single factor solution was the best fit according to Bayesian Information Criterion. The 6-item version of the measure (scored 6-30) demonstrated optimal internal consistency (Cronbach's Alpha 0.86, 95% CI 0.83 to 0.88) with acceptable levels of test-retest reliability (intraclass correlation coefficient 0.84, 95% CI 0.78 to 0.88) and measurement error (smallest detectable change 3.77, 95% CI 3.27 to 4.42) (SE of measurement 2.67, 95% CI 2.31 to 3.16).

CONCLUSION

The 6-item ATEMPT was developed from the six domains of exercise adherence. It has adequate content and structural validity, internal consistency, test-retest reliability and measurement error in patients with MSK pain, but should undergo additional testing to establish the construct validity and responsiveness.

Plant-based diet and COVID-19 severity: results from a cross-sectional study

Although previous findings have shown the beneficial role of healthy eating pattern on the human immune system, the association between plant-based diet and COVID-19 severity has not yet been elucidated. This study aimed to determine the possible role of plant-based diet index (PDI) in COVID-19 severity. This cross-sectional, multicentral study was conducted on 141 patients with confirmed COVID-19. Dietary intakes of the patients were evaluated using a validated food frequency questionnaire. Then, PDI was compared between patients who needed to be hospitalised (considered severe cases), and those who got treatment at home (considered non-severe cases). After adjustment for confounders including age, sex, energy intake and body mass index, lower odds of hospitalisation were found for participants having a greater score of overall PDI (OR per 10 units increase: 0.42; 95% CI 0.22 to 0.80) and healthy PDI (OR per 10 unit increase: 0.45; 95% CI 0.26 to 0.78). In conclusion, our data presented that there is a relation between PDI and lower risk of hospitalisation in COVID-19 patients, possibly through boosting the immune function.

The VISA-A (sedentary) should be used for sedentary patients with Achilles tendinopathy: a modified version of the VISA-A developed and evaluated in accordance with the COSMIN checklist

OBJECTIVE

To develop and evaluate a modified version of the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire, for use in sedentary patients with Achilles tendinopathy, using the Consensus-based Standards for the selection of health Measurement Instruments recommendations.

METHODS

Twenty-two sedentary patients with Achilles tendinopathy completed the VISA-A and provided feedback regarding the relevance, comprehensiveness and comprehensibility of each item, response options and instructions. Patient and professional feedback was used to develop the VISA-A (sedentary) questionnaire. Reliability, validity and responsiveness of the VISA-A (sedentary) was evaluated in 51 sedentary patients with Achilles tendinopathy: 47.1% women, mean age 64.8 (SD 11.24).

RESULTS

Factor analysis identified two dimensions (symptoms and activity) for the VISA-A (sedentary). Test-retest reliability was excellent for symptoms (intraclass correlation coefficient, ICC=0.991) and activity (ICC=0.999). Repeatability was 1.647 for symptoms and 0.549 for activity. There was a significant difference between the VISA-A and VISA-A (sedentary) scores both pretreatment and post-treatment. There was stronger correlation between the pretreatment to post-treatment change in the VISA-A (sedentary) scores (r=0.420 for symptoms, r=0.407 for activity) and the global rating of change than the VISA-A scores (r=0.253 for symptoms, r=0.186 for activity).

CONCLUSION

The VISA-A (sedentary) demonstrates adequate reliability, validity and responsiveness in sedentary patients with Achilles tendinopathy. The VISA-A (sedentary) is a more appropriate measure than the VISA-A for this cohort and is recommended for clinical and research purposes.

Does a corticosteroid injection plus exercise or exercise alone add to the effect of patient advice and a heel cup for patients with plantar fasciopathy? A randomised clinical trial

OBJECTIVE

To compare the effectiveness of patient advice plus heel cup alone (PA) versus PA and lower limb exercise (PAX) versus PAX plus corticosteroid injection (PAXI) to improve self-reported pain in patients with plantar fasciopathy.

METHODS

We recruited 180 adults with plantar fasciopathy confirmed by ultrasonography for this prospectively registered three-armed, randomised, single-blinded superiority trial. Patients were randomly allocated to PA (n=62), PA plus self-dosed lower limb heavy-slow resistance training consisting of heel raises (PAX) (n=59), or PAX plus an ultrasound-guided injection of 1 mL triamcinolone 20 mg/mL (PAXI) (n=59). The primary outcome was changed in the pain domain of the Foot Health Status Questionnaire (ranging from 0 'worst' to 100 'best') from baseline to the 12-week follow-up. The minimal important difference in the pain domain is 14.1 points. The outcome was collected at baseline and at 4, 12, 26, and 52 weeks.

RESULTS

The primary analysis found a statistically significant difference between PA and PAXI after 12 weeks favouring PAXI (adjusted mean difference: -9.1 (95% CI -16.8 to -1.3; p=0.023)) and over 52 weeks (adjusted mean difference: -5.2 (95% CI -10.4 to -0.1; p=0.045)). At no follow-up did the mean difference between groups exceed the pre-specified minimal important difference. No statistically significant difference was found between PAX and PAXI or between PA and PAX at any time.

CONCLUSION

No clinically relevant between-group differences were found after 12 weeks. The results indicate that combining a corticosteroid injection with exercise is not superior to exercise or no exercise.

TRIAL REGISTRATION NUMBER

NCT03804008.

Generalised joint hypermobility leads to increased odds of sustaining a second ACL injury within 12 months of return to sport after ACL reconstruction

OBJECTIVES

To determine the 12-month risk of a second anterior cruciate ligament (ACL) injury in a population of patients with and without generalised joint hypermobility (GJH) who return to sports (RTS) at competition level after ACL reconstruction (ACL-R).

METHODS

Data were extracted from a rehabilitation-specific registry for 16-50-year-old patients treated with ACL-R between 2014 and 2019. Demographics, outcome data and the incidence of a second ACL injury within 12 months of RTS, defined as a new ipsilateral or contralateral ACL, were compared between patients with and without GJH. Univariable logistic regression and Cox proportional hazards regression were performed to determine the influence of GJH and time of RTS on the odds of a second ACL injury, and ACL-R survival without a second ACL injury after RTS.

RESULTS

A total of 153 patients, 50 (22.2%) with GJH and 175 (77.8%) without GJH, were included. Within 12 months of RTS, 7 (14.0%) patients with GJH and 5 (2.9%) without GJH had a second ACL injury (p=0.012). The odds of sustaining a second ipsilateral or contralateral ACL injury were 5.53 (95% CI 1.67 to 18.29) higher in patients with GJH compared with patients without GJH (p=0.014). The lifetime HR of a second ACL injury after RTS was 4.24 (95% CI 2.05 to 8.80; p=0.0001) in patients with GJH. No between-group differences were observed in patient-reported outcome measures.

CONCLUSION

Patients with GJH undergoing ACL-R have over five times greater odds of sustaining a second ACL injury after RTS. The importance of joint laxity assessment should be emphasised in patients who aim to return to high-intensity sports following ACL-R.

Level of pain catastrophising determines if patients with long-standing subacromial impingement benefit from more resistance exercise: predefined secondary analyses from a pragmatic randomised controlled trial (the SExSI Trial)

OBJECTIVE

The primary aim was to investigate the effectiveness of adding more resistance exercise to usual care on pain mechanisms (including temporal summation, conditioned pain modulation (CPM) and local pain sensitivity) and pain catastrophising in people with subacromial impingement at 16 weeks follow-up. Second, to investigate the modifying effect of pain mechanisms and pain catastrophising on the interventions' effectiveness in improving shoulder strength and disability METHODS: 200 consecutive patients were randomly allocated to usual exercise-based care or the same plus additional elastic band exercise to increase total exercise dose. Completed add-on exercise dose was captured using an elastic band sensor. Outcome measures recorded at baseline, 5 weeks, 10 weeks and 16 (primary end point) weeks included temporal summation of pain (TSP) and CPM assessed at the lower leg, pressure pain threshold at the deltoid muscle (PPT-deltoid), pain catastrophising and the Shoulder Pain and Disability Index.

RESULTS

Additional elastic band exercise was not superior to usual exercise-based care in improving pain mechanisms (TSP, CPM and PPT-deltoid) or pain catastrophising after 16 weeks. Interaction analyses showed that pain catastrophising (median split) modified the effectiveness of additional exercises (effect size 14 points, 95% CI 2 to 25), with superior results in the additional exercise group compared with the usual care group in patients with less pain catastrophising.

CONCLUSION

Additional resistance exercise added to usual care was not superior to usual care alone in improving pain mechanisms or pain catastrophising. Additional exercise was, however, superior in improving self-reported disability in patients with lower levels of pain catastrophising at baseline.

TRIAL REGISTRATION NUMBER

NCT02747251.

Energy expenditure, dietary intake and energy availability in female professional football players

Objectives

To quantify energy expenditure and intake in professional female footballers playing on a national and/or international level. Second, to determine the prevalence of low energy availability among these players, defined as <30 kcal/kg fat-free mass (FFM)/day.

Methods

Fifty-one players completed a 14-day prospective observational study during the 2021/2022 football season. Energy expenditure was determined using the doubly labelled water method. Energy intake was assessed using dietary recalls, while global positioning system determined the external physiological load. Descriptive statistics, stratification and the correlation between explainable variables and outcomes were conducted to quantify the energetic demands.

Results

The mean energy expenditure for all players (22±4 years) was 2918±322 kcal. Mean energy intake was 2274±450 kcal, resulting in a discrepancy of ~22%. Carbohydrate intake was below the recommended guidelines on match day at 4.5±1.9 g/kg. The mean energy availability was 36.7±17.7 kcal/kg FFM/day on matchday and 37.9±11.7 kcal/kg FFM/day on training days, resulting in a prevalence of 36% and 23% for low energy availability during the observational period, respectively.

Conclusion

These elite female football players displayed moderate energy expenditure levels and failed to meet the recommended levels of carbohydrate intake. In conjunction with inadequate nutritional periodisation, this will likely hamper performance through inadequate muscle glycogen resynthesis. In addition, we found a considerable prevalence of low energy availability on match and training days.

Effectiveness of a judo-specific injury prevention programme: a randomised controlled trial in recreational judo athletes

OBJECTIVES

To evaluate the effectiveness of a trainer-supervised judo-specific injury prevention warm-up programme on overall injury prevalence.

METHODS

We conducted a two-arm, cluster randomised controlled trial; the Injury Prevention and Performance Optimization Netherlands (IPPON) study. Judo athletes aged≥12 years were randomised by judo school to IPPON intervention or control group who performed their usual warm-up. Primary outcome was overall injury prevalence (%) over the follow-up period (16-26 weeks) measured fortnightly with the Oslo Sports and Trauma Research Centre Questionnaire. A modified intention-to-treat analysis was performed due to COVID-19, with estimates for the primary outcome obtained using generalised linear mixed models. Secondary outcomes included: prevalence of severe injuries, overall incidence, time-loss injuries, exposure, adherence and experiences of trainers and athletes.

RESULTS

269 judo athletes (IPPON: 117, Control: 152) were included. Mean injury prevalence over 16-26 weeks was 23% (95% CI 20% to 26%) in the IPPON and 28% (95% CI 25% to 30%) in the control group. We observed no significant difference of all reported injuries (OR 0.72 in favour of the IPPON group; 95% CI 0.37 to 1.39). Secondary outcomes also demonstrated no significant differences between groups. Specifically, no significant difference of severe injuries was reported (OR 0.80 in favour of the IPPON group; 95% CI 0.36 to 1.78). All trainers and 70% of athletes perceived the IPPON intervention as successful.

CONCLUSION

The IPPON intervention did not significantly reduce the overall and severe injury prevalence. Despite this, we suggest the IPPON intervention be considered as an useful alternative to regular judo warm-up, given the high adherence and the positive clinical experiences of trainers and athletes.

TRIAL REGISTRATION NUMBER

NTR7698.

Determinants of the adoption of injury risk reduction programmes in athletics (track and field): an online survey of 7715 French athletes

OBJECTIVES

To identify individual characteristics associated with the adoption of injury risk reduction programmes (IRRP) and to investigate the variations in sociocognitive determinants (ie, attitudes, subjective norms, perceived behavioural control and intentions) of IRRP adoption in athletics (track and field) athletes.

METHODS

We conducted a cross-sectional study using an online survey sent to athletes licensed with the French Federation of Athletics to investigate their habits and sociocognitive determinants of IRRP adoption. Sociodemographic characteristics, sports practice and history of previous injuries were also recorded. Logistic regression analyses and group comparisons were performed.

RESULTS

The final sample was composed of 7715 athletes. From the multivariable analysis, competing at the highest level was positively associated with IRRP adoption (adjusted OR (AOR)=1.66; 99.9% CI 1.39 to 1.99 and AOR=1.48; 99.9% CI 1.22 to 1.80) and presenting a low number of past injuries was negatively associated with IRRP adoption (AOR=0.48; 99.9% CI 0.35 to 0.65 and AOR=0.61; 99.9% CI 0.44 to 0.84), both during their lifetime and the current season, respectively. These results were supported by higher scores of sociocognitive determinants among athletes who reported IRRP adoption compared with other athletes.

CONCLUSION

Some characteristics of athletes seem to be associated with IRRP adoption either positively (competing at the highest level) or negatively (presenting a lower number of past injuries), whereas all the sociocognitive determinants tested appear to be linked to IRRP adoption. Since many athlete characteristics are difficult or impossible to change, IRRP promotion may be enhanced by targeting athletes' beliefs and intentions to adopt an IRRP.

Effect of an Unsupervised Exercises-Based Athletics Injury Prevention Programme on Injury Complaints Leading to Participation Restriction in Athletics: A Cluster-Randomised Controlled Trial

Objective: To test the efficacy of the Athletics Injury Prevention Programme (AIPP) to reduce the percentage of athletes presenting at least one injury complaint leading to participation restriction (ICPR) over an athletics season. Methods: During the 2017–2018 athletics season, we included in this cluster randomised controlled trial (ClinicalTrials.gov Identifier: NCT03307434) 840 athletes randomly assigned (randomisation unit: athletic clubs) to a control group (regular training) or to an intervention group (regular training plus the AIPP 2/week). Using a weekly online questionnaire, athletes reported the ICPR, training and competition exposures, and, for the intervention group, the compliance with the AIPP. The primary outcome was the percentage of athletes presenting at least one ICPR over the study follow-up. Results: A total of 449 and 391 athletes were included in the intervention and control groups, respectively. From them, 68 (15.1%) and 100 (25.6%) athletes, respectively, provided 100% of the requested information during the follow-up (39 weeks). A total of 6 (8.8%) performed the AIPP 2/week or more. The proportion of athletes who had at least one ICPR over the follow-up period was similar in the intervention (64.7%) and control groups (65.0%), with adjusted odds ratios: 0.81 (95% CI 0.36 to 1.85). There were no between-group differences when comparing separately the subgroups corresponding with the different compliance levels. Conclusion: This cluster randomised controlled trial reported no efficacy of the AIPP. However, the overall response proportion and the compliance with the AIPP in the intervention group were low. In individual sports especially, efforts should be first made to improve the implementation and adoption of interventions.