Risk Factors for Injury in Elite Youth Ice Hockey

I had planned today on writing a sequel to my weekend post on spondylolysis, and I will definitely do so later this week.  But I have hockey on my mind this morning.

Our local team, the Columbus Blue Jackets, fought valiantly this shortened NHL season, and came within a whisker of the playoffs.  The team I grew up with, the Detroit Red Wings, have moved on to the Conference semi-finals, and so if I have any skin left in the game, it is with the Wings.

But I was captivated last night, as I’m sure some of the blog’s readership was, with an extraordinary Game 7 between the Toronto Maple Leafs and the Boston Bruins which brought to mind Jim McKay’s famous line from the “Wide World of Sports”:  “the thrill of victory, and the agony of defeat.


Patrice Bergeron scored the goals at end of regulation and in OT to send Bruins to victory


The Maple Leafs: deflated at the end of a heartbreaking game.

Somehow, the Maple Leafs went from leading 4-1 to losing 5-4 in overtime, as the Bruins, playing at home in Boston, achieved one of the more memorable comebacks in NHL playoff history.

As this was happening, my Twitter feed exploded with #bruins and #leafs posts, as two cities were collectively either shouting with joy or gnashing their teeth.  If you’ve never ‘watched’ a sporting event via Twitter, I commend the experience to you: it’s a bit like tapping into the collective consciousness of whatever group your following. Read more of this post

Youth Sports Violence


What youth sports should be: sheer joy

I woke up this morning to my usual routine:  coffee and the sports page. Both are necessary for me to get up and going in the morning.   Sport, I think many readers would agree, is usually a source of joy, and so it was with equal measures of sadness and shock that I read about the death yesterday of a soccer referee, Ricardo Portillo.

It’s a heartbreaking story, with a 46-year-old gone, a family fatherless, and a 17-year-old who will soon be tried for murder,  whose life will never be the same and whose own family has been irrevocably changed.

All because of one moment of violence.

Mr. Portillo was working in La Liga Continental de Futbol, a youth soccer organization in Salt Lake City, Utah. Apparently he saw the young man commit a shoving foul after a corner kick; when he cautioned the player and gave him a yellow card, the young man punched the unsuspecting Mr. Portillo in the face.   He immediately fell to the ground and was transported to hospital, where he spent a week in a coma prior to passing away.  The details, including clinical descriptions of the victim after the assault, can be found here.

The article gave me pause and got me to thinking specifically about the incidence of such events in youth sports, which I will discuss subsequently.   The specific issue at hand–how often do referees get assaulted on a playing field–was addressed in the NY Times article: “Reliable data on referee assaults at all levels of all sports does (sic not exist, but there have been several violent events worldwide in recent months (my itals),” and the article goes on to enumerate several of these involving referees.  In truth, however, there seem to be no epidemiological data addressing this issue that the reporter could find.

But for one moment, what of the general issue of violence in sports?


Zinedine Zidane in repose

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TREAD carefully with your conclusions! Exercise to treat depression – is it effective?

Depression is one of the most prevalent mental disorders in the World and the global incidence is on the rise. It is already the leading cause of disability, and the fourth leading contributor to the global disease burden according to the World Health Organisation (WHO). WHO is predicting depression to reach second place in the rankings of disability-adjusted life years calculated for all ages and both genders. At least 121 million people are thought to be affected worldwide, with this figure likely being an underestimate.

Exercise has long been thought of as a positive treatment intervention for depression, and many healthcare practitioners recommend exercise as part of a treatment strategy. However, the publication of a new paper by Chalder and colleagues in the British Medical Journal at the start of this month has caused much controversy and debate amongst physicians and patients alike.

Chalder and colleagues reported the results of a UK-based multi-centre, two-armed parallel randomised controlled trial in primary care entitled the TREAD’ study (TREAtment of Depression with physical activity).

The study participants were 361 adults aged between 18 and 69 who had consulted their primary care clinician with symptoms of depression. The intervention consisted of 3 face-to-face sessions and ten telephone calls with a trained physical activity facilitator over an 8 month period designed to offer individually-tailored support for patients to engage in physical activity, and both intervention and control groups were offered ‘usual care’ including antidepressant treatment.

The primary outcome measure was the Beck Depression Inventory score at 4 months follow-up, with secondary outcome measures of the same score at 8 and 12 months, and a self-reported measure of antidepressant use. Physical activity was measured by use of a self-reported 7-day recall diary in which individuals were requested to record 10 minute bouts of light, moderate, and vigorous physical activity, and these were subsequently converted to metabolic equivalents (METS) by multiplying by a factor thought appropriate to each level of activity. An attempt was made to check the validity of this method of data collection by comparison with accelerometry data which found a reasonable correlation between self-reported data and light-moderate physical activity, with less of a correlation at higher levels.

The group found no differences between the groups in Beck Depression Inventory scores at the four, eight or twelve month stage, and no evidence of a decrease in antidepressant use in the treatment group compared with the control group. They concluded that ‘The addition of a facilitated physical activity intervention to usual care did not improve depression outcome or reduce use of antidepressants compared with usual care alone.’

These findings sparked a number of media headlines in different sources including the Daily Telegraph newspaper, the BBC website, and the Guardian newspaper suggesting that exercise is not effective in the treatment of depression.This leap of faith in media reporting in pronouncing that exercise will not help to treat depression as a result of the findings of this trial is quite astonishing but perhaps not surprising.

The devil is, as ever, in the detail and there has been a vociferous response from clinicians and patients alike pointing out the many limitations of the study, including :

1) Questions about the accuracy of self-reported physical activity data ;

2) High drop-out rate during the trial (36.8% and 40.2% at 8 months) ;

3) Lack of a controlled physical activity intervention with doubts about the frequency, intensity, time and type of physical activity undertaken by individuals ;

4) Lack of recording of the exact nature of ‘physical activities’ that were performed by the intervention group including whether these were individual or group activities ;

5) Heterogeneity of possible diagnoses involving depressive symptomatology amongst the study groups (eg bipolar, unipolar, reactive, depressive personality disorder etc) ;

6) Lack of enough well-defined exclusion criteria ;

7) Debate about the suitability of the Beck Depression Inventory for monitoring a treatment response in patients with depression or with depressive symptomatology ;

8) Lack of availability of pre-study physiological parameters (eg VO2 max / Max HR etc) ;

9) Use of an arbitrarily-defined threshold for the ‘desired’ physical activity level ;

10) Lack of controlling for other possible bias and confounding factors (eg psychosocial issues such as alcohol use, unemployment, poverty, previous depressive illness etc).

There is a plethora of evidence for a positive treatment effect of exercise on depression. However, many studies to date have methodological limitations which makes it difficult to make firm conclusions about a treatment effect.

 A Cochrane review conducted by Mead and colleagues in 2010 included 25 relevant randomised controlled trials, many of which had methodological weaknesses, and concluded that exercise did seem to improve symptoms of depression but that the effect sizes were moderate and not statistically significant.

Regardless of the methodological limitations of the TREAD study, given the complicated nature of depression, together with the wider bio-psycho-social associated factors, perhaps a controlled trial to investigate the effects of physical activity on depression is not the correct approach to take, and certainly it looks like few conclusions can be taken from this trial and effectively translated into clinical practice.

If exercise is an effective intervention for some forms of depression then the optimum time, type, frequency, and intensity still remains unknown.

In addition, we are still unsure of the possible mechanisms for a treatment effect of physical activity and exercise on depression. These are complicated and may be divided into physiological and psychological mechanisms including:

1) Physiological – monoamine hypothesis, endorphin hypothesis, regulation of hypothalamo-pituitary axis ;

2) Psychological – distraction, self-efficacy, mastery and social interaction hypotheses.

There may, of course, be a combination of mechanisms involved.

CJSM would like to hear your thoughts about physical activity and exercise as a treatment for depression. In addition, we would like to hear your thoughts about study limitations in general, and issues related to the translation of knowledge into clinical practice.

In the meantime, here are a few blog links mentioning the TREAD study you might want to check out :

1) The lay scientist – Martin Robbins (UK)

2) The ‘Mind’ blog (UK)

3) Scientific American blog (US)

4) About.com depression blog (US)

5) Science Media Centre (NZ)

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1) Chalder M et al. 2012. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. BMJ 2012 344:e2758

2) Baxter H et al. 2010. Physical activity as a treatment for depression: the TREAD randomised trial protocol. Trials 11: 105

3) Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Exercise for depression. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub4.

Time for a break? Competition over the Christmas and New Year period

And so we have reached the Christmas and New Year break, with good-will on offer to one and all. For many of us, this is a time to get away from work – to spend quality time with our family and friends, and to take a breather from the every-day grind of the nine-’til-five. Perhaps some of us will be indulging a little more than usual by way of food, drink and merry-making.

This is, however, not the case for many of those involved in Sport including the athletes themselves and their numerous support staff. In fact, this is often one of the busiest times of the year for those involved in Professional sport, and the fixture calendar can be particularly crowded as the National sporting bodies and Leagues cram in the fixtures, perhaps in order to secure large crowds of seasonal fans and lucrative television rights.

Some sports participants enjoy a break at this time of year, whilst others are perhaps not so fortunate. For example, in the German Football Bundersliga, teams enjoy a four-week period during which the players can take a breather. It is true to say that some teams decide to fly overseas to train and compete in non-league tournaments during this period in order to maintain their in-season fitness, and some players also fly off to take part in National tournaments on other continents, but some teams certainly allow their players time off to spend with their friends and families citing the importance of rest and recouperation for both physical and psychological recovery.

There have been almost annual calls for a winter break for teams in the English Football League for the last few decades, with some managers and players stating that the demands of the football season, together with matches played during the summer period in competitions such as the World Cup and the European Championships, effectively mean that some players have very little time in which to recover and that this leads to adverse physical and psychological consequences for those players together with negative effects on the performance of National teams playing in the summer period and club sides.

Requests for winter breaks in football in the UK have been increasing over the last few seasons, and regional officials and organisations have tended to put the blame for the players’ busy schedules firmly at the door of FIFA and UEFA.

The latest calls for time off during the Christmas and New Year period here in the UK come from former England Manager Sven Goran-Eriksson, the new Sunderland Manager, Martin O’Neill, League One Football Manager Gus Poyet at Brighton, and Wolverhampton Wanderers midfielder Stephen Hunt. However, others are not in agreement with this strategy including Arsenal’s German defender Per Mertesacker who seems to prefer playing in the UK whilst his German footballing colleagues are enjoying some time off back in Germany at this time.

Arguments for the Christmas and New Year break include the following:

  • Allow for physical recovery
  • Allow for ‘psychological recovery’ and protect against adverse psychological effects of stress during the season / travel etc
  • Injury prevention (possibly linked to adverse weather conditions and hard grounds)
  • Improve overall performance over the season

There is a paucity of evidence on which to make these arguments, however.

Looking in greater detail at just one of these arguments, injury prevention, the evidence to support this has been somewhat conflicting. Although I could find nothing in the literature on the effect of a winter break on injury incidence, one might wish to extrapolate from research looking at the incidence of injuries occurring at different times of the season.

In a study published in the British Journal of Sports Medicine in 1998 on the effect of seasonal change in rugby league on the incidence of injury, an increased incidence of injury in summer was demonstrated, and in another prospective study published in the American Journal of Sport Medicine of injury incidence amongst players of one rugby league club over a nine season period, injury risk was found to have greatly increased as a result of changing the playing calendar from the winter months to the spring and summer period.

A study published in 2007 in the British Journal of Sports Medicine on the association of ground hardness with injuries in rugby union showed a seasonal change in ground hardness and an early season bias of injuries.

Orchard discussed the relationship between ground and climactic conditions and injuries in different codes of football, including soccer, rugby league rugby union, American football, Australian football and Gaelic football in 2002, and found an early-season bias for injuries to the lower limb. He concluded that variations in playing characteristics were likely to account for the patterns seen.

I could find nothing in the literature specifically relating to research on the proposed positive effects of a winter break on psychological factors such as mood profiles etc

Should we be offering our players and teams a mid-winter break, and if so, on the basis of which argument(s)?

CJSM would like to hear your thoughts.

In the meantime, all of us at CJSM would like to wish our blog readers a very happy Christmas and New Year, and we devote this blog post to all those who are working with teams over the Christmas and New Year period.

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