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Exercise-Induced Oxidative Stress in the Heat: Do Nutritional Supplements

with Antioxidant Properties Help?

Conference Paper · September 2013

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Medimond - Monduzzi Editore International Proceedings Division

13th AFSM Proceedings

25th-28th September 2013
Kuala Lumpur, Malaysia

Editor

Prof. Dr. John George

MEDIMOND
International Proceedings
 © Copyright 2013 by MEDIMOND s.r.l.
Via G. Verdi 15/1, 40065 Pianoro (Bologna), Italy
www.medimond.com • [email protected]

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form,
or by any means, electronic, mechanical, photocopying,
recording or otherwise, without the prior permission,
in writing, from the publisher.

Printed in December 2013 by Editografica • Bologna (Italy)

ISBN 978-88-7587-691-3

monduzzi editore
International Proceedings Division
is a registered trademark owned by Medimond s.r.l.
Foreword

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

Prof. Dr. John George

Chairman, 13th Asian Federation of
Sports Medicine Congress

©2013 MEDIMOND III

 The Honorable Minister of Youth and Sports, Khairy Jamaluddin (second from right) visiting the booths after the official
opening ceremony of the 13th AFSM Congress held in Kuala Lumpur. He is flanked on the right by the Chairman of the
Congress and President of Malaysian Association of Sports Medicine, Professor Dr John George and on the left by the
CEO of the National Sports Institute of Malaysia, Datuk Dr Ramlan bin Aziz who was also Chief Advisor of the Congress.
 Index

Exercise-Induced Oxidative Stress in the Heat: Do Nutritional Supplements

with Antioxidant Properties Help?
Chee Keong Chen.............................................................................................................................................. 1

Comparative effectiveness of ultrasound guided intratendinous Prolotherapy

injection with conventional treatment to treat focal supraspinatus tendinosis :
randomised control study
George J., Ch’ng Ls., Jaafar Z., Hamid Msa,.................................................................................................. 3

Sports Radiology : Making a diagnosis or solving a problem

George J.............................................................................................................................................................. 9

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

sporting environment”
Hodgson L. ......................................................................................................................................................... 19

Promotion of health related physical fitness of people with intellectual

disabilities
Inal H.S. ............................................................................................................................................................... 23

Integrating physical, mental, emotional and energy components into athletes’

lifestyle to ensure athletic excellence and health
Lal P.R., Balakrishnan B................................................................................................................................... 25

Applications of salivary biomarker measures in sport science

McKune A.J. ....................................................................................................................................................... 39

The eye in sporting activities

Ong K................................................................................................................................................................... 43

Platelet-rich plasma: Facts and fallacies.

Shariff A.H........................................................................................................................................................... 47

Ramadan and Sports Performance

Singh R................................................................................................................................................................ 51

Obesity, physical activity among subjects with Intellectual Disabilities:

Considerations to promote of the level of Physical activity
Subasi F. ............................................................................................................................................................. 55

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

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

young men
Maeda N., Urabe Y., Fujii E., Shinohara H., Sasadai J., Moriyama N., Kotoshiba S., Yamamoto T........ 65

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

Resitance exercise with blood flow restriction in women

Okita K., Takada S., Suga T., Kadoguchi T., Taniura T., Morita N., Yokota T., Kinugawa S.,
Tsutsui H............................................................................................................................................................. 73

Ultrasonographic measurement of the posterior ankle region at various plantar

flexion angles
Sasadai J., Urabe Y., Maeda N., Fujii E., Shinohara H.................................................................................. 77

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

Sogabe A............................................................................................................................................................. 81

Psycho-Social Factors Promoting Psychological Acceptance of Athletic Injuries

Tatsumi T., Takenouchi T. ................................................................................................................................ 87

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

The effects of musical tempo during cycling exercise among undergraduate

sport science students
Illias N.F., Adnan R., Ross V., Sulaiman N., Appukutty M. .......................................................................... 95

Acute changes in blood pressure after physical activities

Raja Yong S., Lee C.P., Moganan M., Misran M.H.I....................................................................................... 107

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

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

Exercise-Induced Oxidative Stress in the Heat: Do

Nutritional Supplements with Antioxidant Properties
Help?

Chee Keong Chen

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

Oxidative stress occurs when the rate of production of free radicals exceed the body’s antioxidant
capacity to detoxify them (1, 2). Free radicals refer to reactive oxygen species (ROS) and reactive nitrogen
species (RNS) which are highly reactive because of an unpaired valence electron. Examples of frequently cited
free radicals include superoxide, hydrogen peroxide, hydroxyl, nitric oxide and peroxyl (3, 4). ROS have been
associated with cellular differentiation, ageing, mutagenesis, carcinogenesis, pathophysiology of numerous
diseases and muscle soreness and damage during exercise (1, 5). Exercise-induced oxidative stress has been
demonstrated in several studies (2, 6, 7). For instance, significant increases in F2 isoprostanes and lipid
hydroperoxides following exhaustive exercise substantiates that exercise induces ROS production (8).
Besides exercise, hyperthermia has been shown to increase oxidative stress in vitro but has not been
adequately assessed in humans in vivo (9). However, Ryan et al. (10) reported that a body core temperature
greater than 40oC increased heat shock protein expression in leukocytes obtained from exercising individuals.
Increased core temperature may increase or contribute to radical formation by uncoupling the mitochondrial
respiratory chain or inhibiting or overwhelming the antioxidant defense mechanism (11, 12). Futhermore,
McAnulty et al. (13) showed that hyperthermia (rectal temperature of 39.5oC) also enhances oxidative stress in
subjects who ran on a treadmill for 50 min in the heat. Hence, the potential relationship between hyperthermia
and ROS is vital due to the significant heat load that can be generated during exercise. This heat load arises from
increased metabolic heat production and exercise in conditions of high heat and humidity.
Oxidative stress is thought to be involved in muscle soreness and damage during exercise (14). The
mechanism by which free radicals induce muscular fatigue remains unclear. However, some investigators have
postulated that free radicals might damage the sarcoplasmic reticulum resulting in reduced calcium release
during depolarisation of the muscle (15, 16) and consequently lead to decreased muscle performance and
muscular fatigue (17, 18). Nitric oxide has also been suggested to have a direct inhibitory effect on contractility
in muscle fibres (19).
The effect of antioxidant supplementation has been suggested as a means of improving skeletal muscle
performance and reducing oxidative stress during exercise (20, 21). Antioxidants are among the most common
sports supplements taken by amateur and professional athletes (22). Most studies to date however, have not
shown any beneficial effect of antioxidant supplementation directly or consuming diets containing large quantity
of antioxidants (20). The studies that have shown positive effects of antioxidants on skeletal muscle endurance
performance were continuous administration of N-acetylcysteine via venous infusion during exercise (23, 24). In
addition, two other studies with pycnogenol supplementation also demonstrated that endurance performance was
improved following acute (25) and 30 days supplementation (26).
We have also carried out several studies on the effects of various nutritional supplements with
antioxidant properties on endurance performance in the heat. These supplements include palm vitamin E,
caffeine, panax gingseng, Eurycoma Longifolia Jack (Tongkat Ali) and honey. The results of these studies are as
follow: 1) Tocotrienol-rich palm vitamin E supplementation decreased lipid peroxidation at rest, and to a certain
extent, during exercise in the heat, as evident from the lower plasma malondialdehyde levels. However, palm
vitamin E at a dosage of 360 mg.day-1 for 6 weeks did not enhance endurance running performance or prevent
muscle damage during exercise in the heat (27); 2) Ingestion of 5 mg of caffeine per kg body weight an hour
prior to exercise improved the endurance running performance in recreational runners in a hot and humid

© Medimond . Q926R9007 1
 13th Asian Federation of Sports Medicine Congress - AFSM (September 25-28, 2013, Kuala Lumpur, Malaysia)

environment (28); 3) Acute supplementation of 200 mg of Panax gingseng consumed an hour prior to the
exercise session did not affect endurance running capacity in heat-adapted recreational runners in the heat (29);
4) Supplementation of Eurycoma Longifolia Jack at a dosage of 150 mg.day-1 for 7 days did not seem to improve
endurance running performance in recreational athletes in the heat (30); 5) Consuming Acacia honey drink at
3ml per kg. body weight every 20 minutes had similar beneficial effect in improving endurance running
performance among recreational athletes in the heat compared with a commercially available sports drink (31).
In summary, supplementation of palm vitamin E, Panax ginseng and Eurycoma Longifolia Jack did not
seem to have any beneficial effect on sports performance in the heat. However, more studies with different
dosages and duration of supplementation are warranted to confirm these observations. On the other hand, we
have demonstrated that caffeine and honey drink may have ergogenic effect on endurance performance in the
heat. Nevertheless, future studies are necessary to substantiate these findings and to identify the precise
mechanisms underlying the observed effects.

References
1. Sjodin B, Hellsten-Westing Y, Apple FS. Sports Med 1990; 10(4):236-254.
2. Marzatico F, Pansarasa O, Bertorelli L et al. J. Sports Med Phys Fitness 1997; 37(4):235-239.
3. Holley AE, Cheseeman KH. British Med Bull 1993; 49(3):494-505.
4. Boveris A, Cadenas E. IUBMB Life 2000; 50(4-5):245-250.
5. Vina J, Gomez-Cabrera MC, Lloret A et al. IUBMB Life 2000; 50(4-5):271-277.
6. Li JX, Tong CW, Xu DQ et al. Eur. J Appl Physiol 1999; 80(2):113-117.
7. McAnulty SR, McAnulty LS, Nieman DC et al. Free Radic Res 2003; 37(8):835-840.
8. Nieman DC, Henson D, McAnulty SR et al. J Appl Physiol 2002; 92(2):1970-1977.
9. Flanagan SW, Moseley P, Buettner GR. FEBS Letters 1998; 431:285-286
10. Ryan AJ, Gisolfi CV, Mosely PL. et al. J Appl Physiol 1991; 70:466-471.
11. Brooks GA, Hittleman KJ, Faulkner JA et al. Am J Physiol 1971; 221:427-431.
12. Hass MA, Massaro D. J Biol Chen 1988; 263:776-781.
13. McAnulty SR, McAnulty L, Pascoe DD et al. Int J Sports Med 2005; 26(3):188-192.
14. Finaud J, Lac G, Filaire E. Sports Med 2006; 36(4):327-358.
15. Davies KJA, Quintanilha AT, Brooks GA et al. Biochem Biophys Res Commun 1982; 107(4):1198-1205.
16. Lovlin R, Cottle W, Pyke I et al. Eur J Appl Physiol 1987; 56(3):313-316.
17. Shindoh C, DiMarco A, Thomas A et al. J Appl Physiol 1990; 68(5):2107-2113.
18. Barclay JK, Hansel M. Can J Physiol Pharmacol 1991; 69(2):279-284.
19. Kobzik L, Reid MB, Bredt Ds et al. Nature 1994; 372:546-548.
20. Peake JM, Sizuki K, Coombes JS. J Nutr Biochem 2007; 18:357-371.
21. Reid MB. Free Radic Biol Med 2008; 44: 169-179.
22. Braun H, Koehler K, Geyer H et al. Int J Sport Nutr Exerc Metab 2009; 19:97-109.
23. Medved I, Brown MJ, Bjorksten AR et al. J Appl Physiol 2004a; 96:211-217.
24. Medved I, Brown MJ, Bjorksten AR et al. J Appl Physiol 2004b; 97:1477-1485.
25. Bentley DJ, Dank S, Coupland R et al. Res Sports Med 2012; 20:1-12.
26. Pavlovic P. Eur Bull Drug Res 1999; 7:26-29.
27. Keong CC, Singh HJ, Singh R. J Sports Sci Med 2006; 5:629-639.
28. Ping WC, Keong CC, Bandyopadhyay A. Indian J Med Res 2010; 132:36-41.
29. Ping FWC, Keong CC, Bandyopadhyay A. Indian J Med Res 2011; 133:96-102.
30. Muhamad AS, Keong CC, Kiew OF, Abdullah MR, Lam CK. Intl J Appl Sports Sci 2010; 22(2):1-19
31. Sukri MN, Ooi FK, Chen CK, Sirajudeen KNS. Proceedings: 16th National Conference on Medical and
Health Sciences, School of Medical Sciences, Universiti Sains Malaysia ISBN: 978-967-5651-03-8, 2011;
217-224.

© Medimond . Q926R9007 2
 13th Asian Federation of Sports Medicine Congress - AFSM (September 25-28, 2013, Kuala Lumpur, Malaysia)

Comparative effectiveness of ultrasound guided

intratendinous
Prolotherapy injection with conventional treatment
to treat focal supraspinatus tendinosis : randomised
control study

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

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

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

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

Materials and Methods

12 patients participated in this randomised controlled prospective study and were randomly divided into
two groups (7 patients in prolotherapy group and 5 patients in control group). Inclusion criteria included focal
supraspinatus tendinosis confirmed on ultrasound and failure of functional score to improve more than 30% after
1 month of conventional treatment after first attendance to our sports medicine outpatient clinic. Exclusion
criteria included mechanical cause of shoulder pain, full-thickness tendon tears, autoimmune diseases, patients
on anticoagulant, congenital or acquired platelet dysfunction abnormality/disorder, haemoglobin level less than
10g/L and/or platelet count less than 100,000/uL, corticosteroid injection within the past 6 weeks and self-
reported immuno-compromised status.
Functional score using the Disability of Arm and Shoulder (DASH) Score and physical examination for
range of shoulder movement were performed by the sports medicine physician at recruitment to study and after
12 weeks.
Patients in the prolotherapy treatment group were seen and treated with 1 to 2 injections of 0.5 to 1ml
mixture of 12.5% Dextrose Solution and 0.5% Lignocaine in bacteriostatic water into area of painful focal

© Medimond . Q926R9001 3
 13th Asian Federation of Sports Medicine Congress - AFSM (September 25-28, 2013, Kuala Lumpur, Malaysia)

tendinosis under ultrasound guidance at one week interval according to relieve of symptoms. Patients in both
groups continued to get standardised physiotherapy regime and mechanical loading for 12 weeks.
Ultrasound parameters assessed were such as intensity area of tendinosis (dB), area of tendinosis on
cross section (mm2), length of partial tears (if present), presence of calcification, periostitis of adjacent greater
tuberosity , doppler flow within area of focal tendinosis, subacromial bursitis and dynamic impingement.

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

Results
There were 14.3% (1 patient) of patients in prolotherapy group and 40% (2 patients) of patients in
control group who show significant improvement at 12 weeks(Table 1). There was no significant difference in
the improvement of functional score between these 2 groups using the Fisher-Exact test (p=0.364).
There were 57.1% of patients in prolotherapy group who showed significant reduction in pain score
while in the control group was 25% (Table 1). However, there was no significant difference of pain score in both
groups using the Fisher-Exact test and p value was 0.247. There was significant difference in sleep improvement
between both groups using the Fisher-Exact test and p value was 0.027 (Table 1). 62.5% of patients in
prolotherapy group improved in sleep score while no patients improved in the control group.
There was significant improvement in shoulder abduction in prolotherapy patients compared to the
control group using Mann-Whitney U Test with p value of 0.030. Range of abduction of patients in the
prolotherapy group increased with a mean of 20.0⁰ while the mean range of patients in the control group
decreased with a mean of 12.0⁰ (Figure 2).

© Medimond . Q926R9001 4
 13th Asian Federation of Sports Medicine Congress - AFSM (September 25-28, 2013, Kuala Lumpur, Malaysia)

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

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

Mean Significant P-value

Baseline 12 weeks Improvement (Fisher-Exact)
(%)
DASH Score
Prolotherapy 60.14 43.89 14.3% 0.364
Control 56.86 46.68 40.0%
Pain Score
Prolotherapy 3.29 1.86 57.1% 0.247
Control 3.20 2.40 20.0%
Difficulty to Sleep Score
Prolotherapy 3.29 2.15 71.4% 0.027
Control 2.20 2.60 0.0%

There was no significant difference in improvement of the ratio intensity of tendinosis to normal tendon
from baseline to 12 weeks between both groups using the Mann-Whitney U and p value was 0.93. However,
there was significant increase in the intensity of the area of tendinosis from baseline and at 12 weeks when both
groups are combined using Mann-Whitney U and p value was 0.009 (Figure 3).
The other ultrasound parameters did not show significant difference between the prolotherapy and
control group. There were also no significant correlation between ultrasound parameters with functional and pain
score.

© Medimond . Q926R9001 5
 13th Asian Federation of Sports Medicine Congress - AFSM (September 25-28, 2013, Kuala Lumpur, Malaysia)

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

Discussion
There is significant reduction of pain score in prolotherapy patients with improvement of movement
such as abduction. In a study on prolotherapy in knee osteoarthritis, there were similar results which was 40%
decrease in pain post 12 months dextrose prolotherapy injections and improvement of movement which is
flexion of 14⁰. (1, 2). In our study with reduction of pain particularly in the prolotherapy group, these patients
were able to lie on affected shoulder during sleep and thus sleep is improved. Prolotherapy improve sleep and
therefore will improve quality of life of patients.
Significant improvement in abduction was noted in prolotherapy patients compared to the control
group. Movement is very important for patients in activities of daily living. A simple action such as flicking on
a light switch will be made possible with improvement of abduction and forward flexion.
Increase of intensity of tendinosis in both groups regardless of treatment, suggest area of tendinosis
regional intensity measurements of the hypoechoic abnormal tendon increases to near similar normal intensity
with treatment in both groups. This suggests remodeling of the tendon. A study on autologous blood injection for
lateral epicondylitis showed the median echogenicity of the tendon significantly increased to near normal-like
tendon appearance as well(3).
There is no significant correlation of ultrasound parameters and function. Zeisig et al (4) and Connell et
al (3) also reported decreased structural defects on ultrasound, though these were not reliably correlated with
clinical gains.

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

© Medimond . Q926R9001 6
 13th Asian Federation of Sports Medicine Congress - AFSM (September 25-28, 2013, Kuala Lumpur, Malaysia)

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

Acknowledgement
This research was funded by Post Graduate Research grant (PPP) Grant No. P0155/2010B of University
of Malaya.
Input on the statistical analysis of this research by Dr Mohammad Nazri Bin Md Shah and Dr Yeong
Chai Hong, lecturers at University Malaya were much appreciated.

Reference
1. Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose
prolotherapy for knee osteoarthritis with or without ACL laxity. Altern Ther Health Med. 2000
Mar;6(2):68-74, 7-80.
2. Reeves KD, Hassanein K. Randomized, prospective, placebo-controlled double-blind study of dextrose
prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of
clinical efficacy. J Altern Complement Med. 2000 Aug;6(4):311-20.
3. Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood
injection for tennis elbow. Skeletal Radiol. 2006 Jun;35(6):371-7.
4. Zeisig E, Ohberg L, Alfredson H. Sclerosing polidocanol injections in chronic painful tennis elbow-
promising results in a pilot study. Knee Surg Sports Traumatol Arthrosc. 2006 Nov;14(11):1218-24.

© Medimond . Q926R9001 7
 13th Asian Federation of Sports Medicine Congress - AFSM (September 25-28, 2013, Kuala Lumpur, Malaysia)

Sports Radiology : Making a diagnosis or solving a

problem

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

Aim:
A Musculoskeletal Radiologist who images Sports Injuries has a major role of detecting the cause of
the patients current symptoms which is their current problem which affects their performance and quality of life .
Methodology : The skill needed to do the above must be acquired from basic training as a resident,
speciality training in Musculoskeletal Radiology, attendance at Basic and Advanced Courses in MSK and then
Clinical attachments . Radiology research should be directed at problem solving .
Results: Basic Training should be by rotation to speciality rather than modality approach as the author
has found accuracy of reporting significant abnormality in joints is only around 50% for those trained by
modality approach. Subspecialty training should depend on a log of cases done rather than duration alone.
Radiology research at UMMC has contributed to cartilage injury detection and mapping of injuries more
accurately .
Conclusion: With use of directed questions, limited physical examination , dedicated rotation under
Musculoskeletal MRI and Ultrasound specialists and applying useful research findings and protocols it is
possible to solve the patients current problem rather than just make a diagnosis.

Text:

Basic Training in Musculoskeletal Radiology during Residency

In an International Musculoskeletal MRI and Ultrasound Course held in Malaysia with myself as
Course Director , homework of actual MRI video cases is given for knee and shoulder examination reveals
accuracy of only about 50% in reporting significant pathology including meniscal tears of the knee. When
questioned the radiologists with such results all mention being trained in a modality approach where they are
attached to the MRI unit doing all sorts of different scans and not attached under a musculoskeletal radiologist
for a two or three months.
A good example of specialty based training is in the Leicester Based Radiology system where the
training is by rotations from first to third year in specialty based training. The summary of their training can be
found at https://www.eastmidlandsdeanery.nhs.uk/page.php?id=829). Speciality based training is also used in
Dubai and website link is as follows:
http://www.dha.gov.ae/EN/SectorsDirectorates/Directorates/MedicalEducation/Services/ResidencyProgram/Doc
uments/Radiology.pdf
Additionally , it is useful to have some sessions where the trainee radiologists can join the orthopaedic
clinic or rheumatology clinic to witness the physical examination being done will help in doing stress tests to
joints while performing ultrasound and improving diagnostic accuracy. This is particularly important in the
ankle examination as the stress tests will help delineate the ligaments such as the CFL much better and avoid
erroneous reports

Subspecialty training and Clinical attachments:

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

© Medimond . Q926R9009 9
 13th Asian Federation of Sports Medicine Congress - AFSM (September 25-28, 2013, Kuala Lumpur, Malaysia)

For Musculoskeletal MRI - the use of the correct technology is also important to enable to get the
necessary information . For instance the MRI machine should preferably be a 1.5 T or higher specification . It
is important to note that not all 1.5 T magnets are of the same quality. One of the ways to assess a good quality
MRI is that it is able to resolve the femoral weight bearing cartilage of the knee which is just 3 to 4mm and pick
up 1-2mm loss of thickness.
A centre where Orthopaedic Surgeons regularly do arthroscopic surgery is preferred and give feedback
to the Musculoskeletal Radiologist helps to improve accuracy .
The training period to learn MSK MRI and Ultrasound for a Clinical Attachment should not be less than
3 months for Clinical Attachment and one year for a proper fellowship. It is important that this time be divided
into Observation, doing the provisional report or initial ultrasound of the patient under supervision which is then
checked and finally doing ultrasound scans on your own in a second room and getting the Consultant to come
and check the scans. Formal assessment should be performed before one is allowed to scan and interpret on
their own.
A Clinical Attachment or doing scans without a superviser or instructor is not beneficial as there is lack
of feedback.

Attending Basic and Advanced Course in Musculoskeletal MRI and Ultrasound.

Continous Professional Education requires individuals to attend course preferably which don’t just have
lectures but also run actual cases of all common pathology which should not be missed .
In the Penang MSK MRI and Ultrasound course of which I am Course Director
(www.penangmskrad.com) MSK MRI videos and MSK Ultrasound Videos demonstrating the MRI and
Ultrasound principles learned during the lectures are shown to bring home the salient points.
The courses should not have more than 1 demonstrator to 6 pax at one ultrasound table and the
ultrasound machines should be of high resolution . There should be at least 2 hours of hands on musculoskeletal
ultrasound time per joint or forearm etc. If possible Video CD of the procedures showing how each region is
done should be shown to the delegates before the ultrasound session and the common pathology after the
practical session so the delegates can recognise the normal images and planes before being shown the videos.
Course materials will usually include some of the up to date articles references and E books and
powerpoints which have been released by speaker for open usage .
The emphasis in the lectures and practical sessions during the course will be on the types of questions
that should be asked , how to select the right imaging modality , showing the simple stress tests and best
positioning for detection of abnormalities.
Musculoskeletal Ultrasound allows one to examine the exact point of point tenderness and to look at
the underlying structure that is the source of the current symptoms of the patient and get this treated.

Continous research and publications to add new insights, techniques and

transfer knowledge.
Scouring the internet for recent articles especially review articles and reading them after a solid course
is to be encouraged. After a solid course many of the images that are in the articles and the text will come
alive and make sense and will form the basis of covering areas that you may want further materials or
explanation not possible to cover in a short course. New techniques can be studied and applied.
Some examples of problem solving with original research at UMMC include
a. Diagnosis of anterolateral menisco –capsular tear which may explain joint line lateral joint line
tenderness which is not associated with a meniscal tear. (1)
b. Researching cartilage protocols which can detect 1mm cartilage defects and internal cartilage
changes before loss of thickness. (Use of CISS 3D sequence Siemens or equivalent) . Background research is
quite adequate in the literature ( 2,3,4,5)
b. Treatment of focal supraspinatus tendinosis with dextrose prolotherapy . to hasten improvement of
clinical symptoms and function.
C. Grading of Tendinosis - so that appropriate treatments can be instituted
a. focal tendinosis
b. Tendinosis complicated with calcification and or tear
c. Partial tear or full thickness tears
d. Bursitis
e. Tenosynovitis
Each of the above needs specific treatment whether it be conservative or with some intervention.

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Here are some examples of methodologies used at UMMC as part of original work to help solve
problems .
Problem: More accurate delineation of cartilage defect up to 1mm in weight bearing area of the knee
and then classification of the region to make it easier for the arthroscopist to find the lesion.
A thesis project in UMMC was done addressing the above issue.

The Methodology was as follows:

Selection and preparation of tissue samples for MR imaging

3 types of tissue samples were selected from the osteochondral specimens to be included in the study:
i) The first type of tissue samples consist of normal cartilage. They are white in appearance on gross
pathology and there is no evidence of fibrillation or loss of height of cartilage.
ii) The second type of tissue samples consist of abnormal cartilage which the thickness is preserved
but the cartilage appears less white (discoloured) and soft on probing.
iii) The last type of tissue samples consist of abnormal cartilage with loss of height compared to the
adjacent sections of cartilage.
The selected tissue samples were cut out with a band saw into wedge-shaped pieces (Figure 1).

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

Subsequently, the wedge-shaped pieces are arranged in a plastic container submerged under normal saline
solution. The specimen pieces are being anchored with rubber bands on to a cutting board submerged under the
solution with rubber bands. The orientation of each specimen piece is as follows (Figure 2)
i) cartilage surface facing anteriorly
ii) bone surface facing posteriorly
iii) widest width is at the base
iv) narrowest width is at the apex

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

MR imaging of the specimens

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

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

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

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

TR TE Flip Matrix Pixel FOV No. of Effective TA

(ms) Angle (%) Size (mm) Slabs Slice
(degree) (mm) Thickness
(mm)

CISS- 0.52 x
12.3 5.9 70 60 160 1 1.5 3 min 25 sec
3D 0.31

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

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

The results were as follows :

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

First MRI
First Actual Cartilage
Cartilage Thickness
Thickness Measurement by
Measurement Trainee
Radiologist

Pearson Correlation 1 .805 (**)

First Actual Cartilage Thickness
Sig. (2-tailed) .000
Measurement
N 114 114

Pearson Correlation .805 (**) 1

First MRI Cartilage Thickness
Measurement by Trainee Sig. (2-tailed) .000
Radiologist
N 114 114

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

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

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Conclusion of the above study :

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

Problem 2 : Translating the correct location of a cartilage defect noted on

weight bearing area of Femoral cartilage in a manner that can be understood to
the arthroscopist so they understand where to look for the small defects of
cartilage . UMMC Thesis.

Solution :
A mapping system was derived from studies at our institution to be able to tell the orthopaedic surgeon
where the lesion is following the standard way we do our sagittal scans .
The mapping system is as follows:
The mapping system we use is easy as it follows the ICRS system and easily understood by orthopaedic
surgeons.
The system is based on the appearance of cartilage from the sagittal sequence of a cartilage specific
sequence like 3D CISS (Siemens) or Balanced FFE (Philips). In this classification, the outermost sagittal image
shows the weight bearing area of the femoral condyle, which is limited by the outer border of the anterior and
posterior horns of the medial and lateral menisci. The posterior femoral condyle forms the non weight bearing
area on this image. These two areas have been designated A2 and A3. A3 is usually correlated arthroscopically
by the cartilage beyond 45 degrees of flexion (Figure 6). The sagittal image that first shows cartilage anterior to
anterior horn of the menisci reflects the next section. The cartilage anterior to the meniscus is identified as B1
and B2 and B3 (Figure 7) reflects the corresponding areas as A2 and A3, except being more central in the
femoral condyle. The next region of interest is the trochlea region of the femoral condyles. In this plane there is
no central weight bearing area or posterior region of the cartilage and is identified as C1 (Figure 8). Therefore in
this proposed simple classification, the area 1 refers to the cartilage anterior to the meniscus on the MRI in which
the knee may normally have up to 5 degrees of flexion. Area 2 refers to the weight bearing areas of the femoral
cartilage and area 3 the cartilage posterior to the meniscus which is usually the cartilage noted beyond 45
degrees of flexion on arthroscopy and posterior to the meniscus on the sagittal views. The patella cartilage can be
described as being on the medial or lateral facet of the patella or the median ridge. The tibial plateau cartilage
can be identified as being on the medial or lateral tibial plateau anterior or posterior region (T1 and T2
respectively). Thus, a lesion of the anterior half of the lateral tibial plateau would be graded as LT1 and a lesion
on the posterior half of the medial tibial plateau identified as MT2.
The orthopaedic surgeons used the ICRS mapping system to point out the location of the cartilage
lesion (see appendix). Area 1, 2, 3 (as mentioned above) correspond with anterior, central and posterior region
respectively, and area A, B, C correspond with medial, central and lateral region respectively of the ICRS system

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A3

A2

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

B3

B1

B2

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

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C1

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

References :
1. Radiological classification of meniscocapsular tears of the anterolateral portion of the lateral meniscus of the
knee. George J, Ramlan AA, Saw KY et al. Australas Radiol. 2000 Feb;44(1):19-22
2. Cartilage T2 Assessment at 3-T MR Imaging: In Vivo Differentiation of Normal Hyaline Cartilage from
Reparative Tissue after Two Cartilage Repair Procedures—Initial Experience. Goetz HW, Tallal CM,
Stephan EM , et al. April 2008 Radiology, 247, 154-161
3. MRI Imaging of Cartilage and its repair in the knee – a review . Trattnig S, Domayer S, Welch GW et al.
Eur Radiol (2009)19: 1582-1594
4. Arthroscopic Measurement of Cartilage Lesions of the Knee Condyle : Principles and Experimental
Validation of a New Method. Robert H, Lambotte JC, Flicoteaux R. Cartilage 2011:2(3)237-245.
5. Recent advances in MR of articular cartilage . Gold GE, Chen CA, Koo S , Hargreaves BA, Bangerter NK.
AJR Am J Roentgenol 2009 September : 193(3) :628-636

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“Duty of Care, Roles and Responsibilities of a

practitioner working in the sporting environment”

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

About the Author

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

Abstract
The purpose of this keynote address is to raise the awareness on what working within the sporting
environment actually means to health care professionals. It will probably be of most benefit to those aspiring
to work within sport and provide information about planning and accepting such a role. The intent is not to
discourage one from accepting a role within sport but to ensure one is prepared for anything that may
reasonably be expected to encounter so that it can be dealt with appropriately. Ultimately this is the insurance
policy for both one’s-self and one’s-athlete and thus the sporting environment.
The sporting environment is a totally different field of medicine to the hospital or clinical setting.
Whilst some skills are transferable between settings additional skill sets are also required to ensure that the
sporting environment is managed appropriately.
Guidelines, policies and procedures exist within the medical setting of a hospital, practice or clinic but
dependent on the sport or governing body of sport that some clinicians will work with, this may not be the case.
So the questions transpire – “what is your role?” “what are your responsibilities?” “to whom does your duty of
care apply?”
Sports medicine provision to any team adds an advantage to that team and also acts as an insurance
policy for that team. Healthy and fit players can compete, those with injuries cannot. Any team that aspires to be
anything requires fit and healthy players participating.
Accepting a role within a sporting environment requires one reflecting on several considerations that are
not just reliant on having a medical or health care related degree. Some considerations are;
- The duty of care
- Roles and responsibilities
- Risk assessment

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- Medical recording keeping and confidentiality

- Medical equipment needs of the sport
- Pre hospital emergency care management for competition and training
- Education of self and athletes
- Medical indemnity and professional insurance
In accepting a sports medicine role within a sporting environment, a significant responsibility ensues.
Whether your role is paid or honorary is irrelevant, the same duty of care applies.
A medical qualification or allied health care qualification is not enough, but forms the basis of your
suitability to a role within sport. As with any speciality one chooses to work in, further expertise in that area is
required. Sport and exercise medicine is no different. One will always be judged against what their peers would
do in the same situation, in essence the standard of care must be to a standard that a reasonably prudent
professional would provide under similar circumstances [1].
In law, a tort is an injury suffered by an individual as the result of another individual's conduct. The law
provides injured individuals the right to be compensated through the recovery of damages. Torts may be
intentional or unintentional, negligence is an unintentional tort. Negligence law was founded on the belief that
those harmed as the consequence of others' carelessness or failure to carry out responsibilities properly were
entitled to be compensated. It is based on four legal elements first that there is a duty of care, second that that
duty is breached, third that the breach caused harm and lastly actual harm occurred [2].
Medical negligence cases already exist, in the UK they are based on the Bolam test. The majority of
peers who come under scrutiny do so because they did not have the required skills to carry out the duty of care
that they accepted [3-6].
A recent suit was established in the USA (August 2013) against the coaching staff, athletic trainer,
NCAA and helmet manufacturers for the death of a 22 year fullback who died in contact training. Repetitive
trauma over several days existed resulting in a final collision on the third day resulting in an acute subdural
haematoma and massive vascular engorgement. (7,8). The family claim it is inconceivable with all the attention
on concussion management that no unified enforcement existed to prevent the dangerous practice or to ensure
proper medical attention. The death is felt to have been preventable and forms the basis of their claims of
negligence against all the parties named [7]. Largely, established medical malpractice govern claims by athletes
for injury or death caused by improper treatment by health care providers [9]. Providing treatment of injuries
and medical clearance for sports participation involves legal as well as medical issues. The threat of lawsuits
exists for the sports medicine professional whether the athlete is allowed to play or not. Allied health care
professionals and team physicians have been sued for prematurely clearing athletes, and also been sued for not
permitting athletes to play [10-13].
One’s duty of care is foremost to their athletes irrespective of the management system within the sport
and who is the line manager or salary provider. Essentially the medical team responsible for the athletes cannot
also be responsible for the crowd, another team should exist for the sole purposes of crowd care. That is not to
say, in an emergency one would not have an ethical and moral ‘vicarious’ duty to act to assist with crowd care
having firstly dispensed with one’s own duty of care, in essence stopping sport before assisting so that no further
harm could ensue to an athlete.
Handing over one’s duty of care should also be carefully considered. This is only complete if handed
over to an established health care professional and ensuring relevant information regarding the mechanism,
assessment and treatment is relayed. This is not discharged if the athlete is handed over to a first aider (non
qualified person) for transport or if pertinent information is excluded. As part of the role one must ensure they
meet, greet and establish relationships with those that may assist in onward referral or hospital transfer to ensure
the transfer of the duty of care. A suit in the USA resulted in the court awarding $1.5 million dollars in damages,
including $450,000 from the athletic trainer for neglecting to hand over relevant information that would have
assisted with onward care [14].
National governing bodies of sport and the sporting team/event also have a duty of care and generally
one of these is the provision of medical support, the role one is accepting. It is imperative that one is aware of
what role and what responsibilities are being accepted. Essentially one should establish a job description and
contract with these specifically detailed, this may prevent litigious situations from occurring (15).
A risk assessment of the sport, venue and potential injuries is essential. Establishing action plans for all
case scenarios as well as risk reduction procedures is paramount in establishing your duty of care. One of the risk
assessments is self-reflection. Does one have the skills required to work in this sport? Does one have the up-to-
date knowledge and experience to accept the role being offered? Does one have access to the emergency
equipment that may be required to prevent a life threatening injury? Whilst risk management procedures will not
help sports medicine professionals defend themselves in a lawsuit they should help prevent litigious situations
from occurring. A physician and health care professional has a duty to conform to good and accepted standards
of medical care in determining whether an athlete continues to participate. In Classen v Izguierdo, a ringside
physician refused to stop a boxing match in which a participant received several blows to the head. The boxer

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died from the multiple head injuries sustained, and the court indicated in the opinion that the failure of the
physician to keep the athlete from competing may have constituted malpractice [16]. In the case of an athlete
with a head injury, there is uncertain potential for permanent disability or death. Given the extreme risks, it
seems reasonable to err on the side of caution [17].
Medical standards should be up to date and updated periodically as sport and exercise medicine practice
evolves for athlete safety. Adherence to outdated sports medicine guidelines is not a recognized defense. It is
imperative that has a health care professional that skills and knowledge relevant to the sport are maintained. An
example is if the sport has a propensity to concussions then the established management principles outlined in
Zurich 2 [18] should be followed. If a risk of cervical spine injury and extrication exist then the clinicians should
be up to date in emergency care. In the UK, there has been training in pre-hospital immediate care for pitch side
physicians and therapists for the past decade [19]. A knowledge of basic first aid is not enough to work in a
sporting environment, an established sports course that focuses on emergency care is an essential pre-requisite to
accepting a role in sport [15]. Many courses exist but choose wisely and ensure the course meets the demands
and is run by experienced instructors. Example courses can be viewed at www.corobeussportsconsultancy.co.uk.
Thankfully the incidence of catastrophic and severe injuries in the athletic population is low, however
when these events do occur pitch-side, the SEM practitioner present will be expected to deal with this quickly
and appropriately and may have very little emergency experience. Sudden cardiac arrests and deaths in sport
have made media headlines recently [20-22] and whilst infrequent do occur. Whilst risk assessment can look into
preventative measures such as cardiac screening in this scenario, not all can be prevented and effective
management in a life-threatening scenario will be required with timely access to essential equipment. One must
be prepared for this and have all required equipment to hand [23]. The same applies to the common injuries. The
supply of this equipment is subject to debate and should be provided to you by the sport but it is the
responsibility of the medical staff to check the equipment is present and in working order before any sporting
event begins. The level of sport and affluence of the sport will decide what equipment is essential and what is
only desired, but as part of one’s risk assessment one must decide what one can and cannot do without to ensure
the safety of their athletes. Education of self and others in the use of the equipment is also essential.
Finally medical record keeping and documenting injuries as well as medical examinations and pre
participation screening is an essential role and must be kept and stored in a secure location. Patient
confidentiality is paramount and sharing of information cannot be done without the express consent of the
athlete.

References
1. Osborne, B. Principles of liability for athletic trainers: Managing sport related concussion. J Athl Train
2001;36(3):316-321.
2. Dobbs DB. Torts and Compensation. St. Paul, MN: West Publishing Co; 1993.
3. Bolam vs Frien Hospital Mangagement Committee (1957) 1 WLR 583
4. Watson vs Bristish Boxing Board of Control (2001) QB 1134
5. Bolitho vs City Hackney Health Authority (1997) 4 All ER 771
6. Brady vs Sunderland AFC and Boobis & England (1998) CA (unrep)
7. Derek Sheely et al v NCAA et al http://nflconcussionlitigation.com/
8.http://www.washingtontimes.com/news/2013/aug/22/death-frostburg-state-player-dereksheely-due-egre/
9.Mitten MJ. Team physicians and competitive athletes: allocating legal responsibility for athletic injuries. U Pitt
Law Rev. 1993;55:129.
10. Kampmeier v Nyquist. 553 F.2d 296 (2d Circ. 1977)
11. Grube v Bethlehem Area School District. 550 F. Supp. 418 (E.D. Pa. 1982)
12. Wright v Columbia University. 520 F. Supp. 789 (E.D. Pa. 1981)
13. Poole v South Plainfield Board of Education. 490 F. supp. 948 (D.N.J. 1980)
14. Pinson v State. 1995 Tenn. App. LEXIS 807
15. Hodgson, L. Working in sport and exercise medicine – Be Prepared part 1 SportEx med 2010;46;17-22.
16. Classen v Izquierdo. 137 Misc. 2d 489 (1987)
17. Knapp v Northwestern University. 101 F. 3d 483 (1996 U.S. App.)
18. McCrory, P. Meeuwisse, W,H. Aubry M et al Consensus statement on concussion in sport: the 4th
International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med
2013;47:250–258
19. Hanson J. Sports pre-hospital immediate care courses in the United Kingdom – attempting to “treat” sudden
cardiac death. Scottish Medical Journal 2010;55(2):35
20. Fabrice Muamba suddently collapses FA Cup Semi Final, YouTube 19 March 2012 http://spxj.nl/L20iAb

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21. MacAree, G. Poermario Morosini dies following heart attach on pitch, SBNATION on YouTube 31 May
2012 http://spxj.nl/L7Ayzu
22. Olympic swimmer dies: Norwegian hopeful Alexander Dale Oen suffers cardiac arrest, The Mirror 1 May
2012 http://spxj.nl/KxsHvW
23. Hodgson, L. Sudden Cardiac Death in Sport – Be Prepared! Part 3. SportEx Med 2012;53:20-25.

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Promotion of health related physical fitness of

people with intellectual disabilities

Inal H.S.
Yeditepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Istanbul, Turkiye

Children with intellectual disabilities may usually have delay in their motor functions besides their
intellectual, social, communicational or academic activities (Melville & et.al. 2005). For instance, they present
some inadequacy in their balance, speed, endurance, strength, flexibility, agility, reaction time and posture when
compared with their pears (Winnick & Short, 1999). Cantell & McGhee (2006) states that the insufficiency of
cognitive perception and attention of the children with intellectual disabilities may exhibit decreased
perceptual-motor skills, spatial awareness, body image, kinesthetic sense, balance and posture. Thus, the
interaction of these features may detoriate their health related physical fitness and decrease their integration to
physical, recreative and sportive, as well as social activities.
A study we have done on thirty (30) children at educable intellectual level studying in a primary and
vocational school who were between the ages of 7-15 years showed that they had mild to moderate postural
changes as pesplanovalgus, round shoulder, forward protruded head, depressed chest, knee deformities, lordosis,
kyphopsis, lordosis and abdominal bulging. Deformities of knee joints (varus-valgus, P < 0.01 and recurvatum, P
< 0.05) were also found negatively related with the duration of stair climbing and walking, respectively.
Additionally, there was a negatively significant relationship between the handgrip strength and the duration for
crouching and standing up (P < 0.05). Thus we concluded that, postural changes and hand grip strength of the
children with intellectual disabilities may effect their balance, and their speed of walking and stair climbing (Inal
et al. 2008) that are important activities may effect their everyday life.
Physical activity and sports are considered as effective means to improve posture and increase the
physical capacities, especially the strength, speed and endurance, overall the neuromuscular co-ordination of the
children with intellectual disabilities (Lewis & Pinkham; Pinkham, 2005). As an inherited feature, reaction time
that is a determinant factor of speed (Bompa, 1990) may also be improved. A study aiming to search the
reaction time of the youngsters with mild to moderate intellectual disabilities actively involving with table
tennis (n = 14; 17.21±1.11 yrs) and the sedentary (n = 13; 15.46±0.08yrs) whom are only joining physical
education classes in their schools, have showed that the children involving with sports (514.44 ± 1.04msec)
were having shorter duration of reaction time then the sedentary (642.27 ± 2.54msec) (P < 0.05) (Koldas & Inal,
2004). Thus, the physical activity and the sports training programs assigned according to the achieved results of
the assessment interventions on the health related physical fitness of children with intellectual disabilities can
promote their performance.
On the other hand, the physical inadequacies of the children especially with severe intellectual
disabilities may drag them into a more motionless and sedentary life; consequently some chronic illnesses such
as musculoskeletal, cardiac and respiratory diseases, obesity and diabetes mellitus could be arisen that decrease
their quality of life and threaten the life (Hahn & Cella, 2003; Moran et al., 2005). Obesity is a serious life
threatening problem of the people with intellectual disabilities. They are 30-50 % more obese when compared
to general population (Moran et al., 2005). Melville et al. (2005) have reported increased incidence of obesity
among female with Down’s syndrome. The BMI of the youngsters with intellectual disabilities was reported as
for tennis players 27.45 ± 2.65 kg/m² and for sedentary 33.81 ± 0.0 kg/m² that were both overweight and
obese level, respectfully (Koldas & Inal, 2004) according to their age and gender (Cole et al., 2000). In relation
to these data, since they are more liable to gain weight, regular physical activity and sports as effective tools to
control weight and of course to decrease the risks of cardiovascular problems (Lewis & Pinkham, 2005) should
be disseminated among the people with intellectual disabilitis as a positive health behavior.
Overall, for promotion of the physical capacity of the people with intellectual disabilities and for
assessing the achieved improvements after certain physical activity or sports training programs, which may be
for recreative or competitive purposes, they need to be evaluated regarding to their health related physical
fitness.
The valid and reliable tests in disability sports give us the opportunity to utilize the standard norm tables
(Short, 2005; Skowroński et al., 2009) in addition to the facilitation of the comparative studies in the area of
disability sports. Among the tests available in literature, Test of Gross Motor Development-TGMD II, is specific
for the Basic Movements period, is developed particularly to evaluate the gross motor development of pre-

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school and elementary school children that are between age 3 and 10 with/without intellectual disabilities
(Ulrich; Palisano, 2000; Simons et al. 2007). The Brockport Physical Fitness Test is another common and
practical test, which was developed by New York State University. It is for children and adolescents between
age 10 and 17 who are healthy and having disabilities (Pinkham et al., 2005). However it is possible to comprise
a special test battery particular to an individual, or a specific disability, or an age group by choosing from among
the 27 tests it contains. The other common test named as Eurofit Test Battery is developed in Europe, as a
method that can be used for individuals of all age groups and levels of physical activities (Eurofit, 1988). As
Skowroński et al. (2009) have stated, some modifications in Eurofit Test Battery proposed for children
disabilities and some practices have been simplified and made more efficient especially for the individuals with
intellectual disabilities under the name of Eurofit Special.
The collected data may provide information about the health related physical fitness level of the
children interested with adapted sports. They also furnish the professionals as well as the families about the
developmental process of the children from their fundamental movement phase towards the specialized motor
skills within the limits of their physical and intellectual capacities. Additionally, they supply detailed
information to the couches or the physical education teachers whom may do counseling the individuals and the
families to practice sports most suitable for their physical condition and skills (Munson et al., 2004).

References
1-Bompa OT (1990). Theory and Methodology of Training. The key to athletic performance. Second Edition.
Kendal/Hunt Pub.Iowa.
2- Cantell M & McGehee D. (2006). Movement quality in children with developmental delay: Midline and
weight sensing as markers of adaptive movement. Body, Movement and Dance in Psychotherapy, 1, 129–
41.
3- Cole TJ, Bellizzi MC, Flegal KM & Dietz WH. (2000). Establishing a standard definition or child overweight
and obesity worldwide: international survey. British Medical Journal 6;320 (7244):1240-3
4- Eurofit (1988). Report of the European Conference Special Olympics 1988-1990. The Road to Europeanian
Headquarters (pp.78-79).
5- Pinkham F, Haley SM, Rabin J & Kharasch VS. (2005). A Fitness Program for children with disabilities.
Physical therapy, 85,1185-1200.
6- Koldas H & Inal S. (2004). Effects of sports on the reaction time of the children with Down’s Syndrome. 7th
International Congress of Sports Medicine Association of Drama, Greece. 29April-2 May 2004,
7- Hahn EA & Cella D.(2003). Health outcomes assessment in vulnerable populations: Measurement Challenges
and Recommendations. Archives Physical Rehabilitation and Medicine, 84 , Supp l2, 35- 42.
8- Inal S, Kaya B, Kırandı Ö, Orhun B, Güngördü O, Keser A & Donuk B. (2008). Health Promotion of
Children with Mental Challenges Via Sports and Physical Activity. The 50th ICHPER-SD Anniversary
World Congress, May, 9-12, Kanoya, Kagoshima, Japan.
9- Lewis CL & Pinkham F. (2005). Effects of aerobic conditioning and strength training on a child with Down
syndrome: a case study. Pediatr Phys Ther. Spring;17:30-6.
10- Melville CA, Cooper SA, McGrother CW, Torp CF & Collacott R. (2005). Obesity in adults with Down
syndrome: a case-control study. J Intellect Disabil Res. Feb;49(Pt 2):125-33.
11- Moran R, Drane W, McDermott S, Dasari S, Joy B, Scurry JB & Platt T. (2005). Obesity among people
with and without mental retardation across adulthood. Obesity Research 13:342-349.
12- Munson D, Corbin SB & Pastorfield C. (2004). Fitness survey: survey of Special Olympics coaches
regarding athlete fitness. Special Olympics, health athletes, health promotion. (www.
Specialolympics.org/healty_athletes.aspx)
13- Simons J, Daly D, Theodorou F, Caron, C, Simons J & Andoniadou E. (2007). Validity and reliability of the
TGMD-2 in 710-year-old Flemish children with intellectual disability. Adapted Physical Activity
Quarterly, 25:71-82.
14- Short FX. (2005). Measurement and assessment. (In) Adapted physical education and sport. Joseph P.
Winnick Editor, p.55-76 Human Kinetics, Illinois.
15- Skowroński W, Horvat M, Nocera J, Roswal G & Croce R. (2009). Eurofit Special: European Fitness battery
score variation among individuals with intellectual disabilities. Adapted Physical Activity Quarterly,
26:54-67.
16- Ulrich DA. (2000) Test of Gross Motor Development. Austin, TX: Pro-ed. Publishers.
17- Palisano RJ, Hanna SE, Rosenbaum PL, Russel DJ, Walter SD, Wood EP, Rania PS & Galuppi BE.
(2000). Validation of a model of gross motor function for children with Cerebral palsy. Physical Therapy,
80: 974-985.
18- Winnick JP & Short FX. (1999). The Brockport physical fitness training guide. Human Kinetics, Illinois.

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Integrating physical, mental, emotional and energy

components into athletes’ lifestyle to ensure athletic
excellence and health

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

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

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

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

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

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

Hydration status and psychophysiology:

In a case control study(26) on a convenience sample of 60 collegiate, basketball women(18-22 years), 30
training in open-air at temperatures 31-37oC and 30 matched counterparts training in environmentally controlled
centres, selected via purposive sampling, the effect of body hydration status on their psycho-physiological profile(PPP)
was studied. The pre and post exercise values of PPP(heart rate, simple reaction time, choice reaction time and electro-
dermal response) was measured; simultaneous measurements of body hydration status(urine specific gravity and urine
pH) and perceived exertion during exercise were made using heart rate monitor, reaction timer and electrodermal
monitors from Medicaid, India; multistix strips and Borg’s Scale respectively.
At start of the study, screening ensured similarity in the subjects’ age, body mass index, total body
water, physical activity level, total daily energy expenditure and nutrient intake. A stringent selection criteris
ensured that the two groups - the college basket ball team (BBG) and the college athletes training in a fitness
centre(CG) were similar in all aspects except that the CG was training in controlled, comfortable (20-24oC and
relative humidity of <50%) environment.
Results of the study indicated that there was no significant difference in pre-exercise body hydration
status and psycho-physiological parameters between both groups. Table 1,2 and 3 describe the pre-exercise and
post- exercise body hydration and psychophysiological status of the two groups.

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

USG UpH

BBG CG BBG CG

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

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

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

t value 7.61** 6.46** 3.86 ** 6.46**

(Paired t-test)

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

& t = 2.10, significant at 0.05 level

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

Parameter Group Pre (Mean ± SD) t-value
HR BBG 73.13±5.00 1.93NS
CG 70.83±4.84
RTS BBG 0.181±0.02 0.15 NS
CG 0.180±0.02
RTC BBG 0.240±0.03 0.19 NS
CG 0.239±0.03
GSR BBG 457.43±122.57 0.56 NS
CG 440.40±110.81
NS- Not significant

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

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

Parameter Group Post (Mean ± SD) t-value

HR BBG 86.90±8.19 2.59*
CG 81.33±8.43
RTS BBG 0.219±0.03 1.51NS
CG 0.206±0.03
RTC BBG 0.316±0.03 0.87 NS
CG 0.286±0.03
GSR BBG 359.27±121.97 0.23 NS
CG 352.07±123.59

* Significant at 0.05 level; NS not significant

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

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Figure 1: Rated perceived exertion of CG and BBG

20
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The ratings for perceived exertion ranged from ‘no exertion at all’ to ‘extremely hard’ throughout the 90
minutes session for BBG, whereas they ranged from ‘no exertion at all’ to ‘hard’ in CG, indicating that CG was
not as fatigued as BBG. No subject from either group reported maximal exertion during the exercise session.
This data indicated that the collegiate basketball group perceived the same quantum and intensity of exercise as
harder than their counterparts who were exercising in controlled comfortable environments.

Knowledge, attitude and practices regarding hydration

Data on the subjects’ knowledge, attitudes and practices(KAP) related to hydration, was collected in
detailed questionnaires.
Results of this data showed low awareness and faulty practices in both groups (26b) with respect to all
knowledge aspects such as weight and urine monitoring, quantum of fluids needed, type, concentration and
temperature of fluids that are beneficial.
Similar results were observed in another study by Jessri et al, 2010 on 66 basketball players and 141
football players from 4 medical and 8 non-medical universities in Tehran to assess the nutrition knowledge and
the factors determining knowledge and concluded that there is a need to enhance knowledge related to hydration
among athletes.
Both groups had a positive attitude and the awareness that hydration was important for exercise
performance, although all subjects had a low score in their hydration practices. Hence, the poor body hydration
status of the athletes could be attributed to the lack of awareness regarding important aspects of hydration in
sports, due to which they were unable to make wise choices to strengthen their hydration practices.
In this formative study, post exercise, the loss in body mass averaged 0.19% - 0.4% in the two groups,
indicating a subtle level of dehydration of <1% in both groups. The body hydration indicators and PPP
deteriorated significantly(p<0.01) in both groups when compared with their pre-exercise levels, indicating post-
exercise deterioration. EG showed significantly higher values of urine specific gravity(p<0.01), urine
pH(p<0.05) and heart rate(p<0.05), when compared with CG, post exercise and a positive covariance between
urine specific gravity and heart rate, implying that levels of dehydration and deterioration in psycho-
physiological response may co-vary or be related. This study concluded that even subtle dehydration of 0.4%, in
hot environment, amounting to small water loss of 190-220ml particularly due to poor hydration knowledge and
practices, may induce decrements in the PPP (HR). This was later supported in another study (27) at 0.7%
dehydration, which also observed a deterioration in choice reaction time along with heart-rate and perceived
exertion, post exercise. Hence, such subjects may be at a potential risk of lower sports or occupation
performance and an increased risk of injuries (our later study(27c) did not find significant links with injury
status) and impaired long term health status due to psycho-physiological deterioration caused by the stress of

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

Effect of the awareness tool and a hydration strategy on the hydration status
and psychophysiology of collegiate athletes
The hydration awareness tool prepared after the formative study(26) reported earlier in this paper, was
utilised in another study(27b) on collegiate basketball players, aimed at enhancing hydration knowledge and
practices of athletes training in uncontrolled environments, attaining a rehydrated status after removing barriers
to improved hydration status through a fluid replacement strategy using three popular fluids and studying its
effect on the subjects’ PPP. Forty college going women basketball players, selected via criteria based purposive
sampling, were randomly divided into CG and EG. Hydration KAP (via questionnaire), PPP (HR & CRT); body
hydration status (USG & UpH) and perceived exertion was studied. The awareness tool was utilized for
improving the hydration knowledge and practices of CG and EG, after which, an implementation strategy for
fluid replacement (WOP) was developed and implemented in the EG only. The effect of hydration with three
fluids- Water, Lemon water and Glucon-D on the PPP was also assessed. All subjects’ baseline data and data
after implementation of the tool was collected and data after the implementation of the hydration strategy was
taken in the EG alone.
At Baseline: T- test between the baseline data of the two groups revealed that there was no significant
difference in the knowledge related to hydration between both the groups i.e. both the groups began the study
with similar hydration knowledge (t= 0.64, NS). This observation supports the earlier studies in concluding that
there is a need to enhance knowledge related to hydration
After implementation of the awareness tool: To compare the changes in knowledge related to
hydration in each group before and after the implementation of the tool, the paired sample t-test was used. There
was a highly significant difference obtained in both the groups indicating that the awareness tool can bring in a
significant improvement in the knowledge regarding hydration (Table4).

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

Baseline 10.55 ± 3.81 9.65 ± 4.95

After tool implementation 23.55 ± 5.57 26.75 ± 7.26

T value 9.97* 15.09*

*Significant at 0.01 level

When scores of both groups were compared, using t- test, it revealed no significant difference in the
knowledge related to hydration between both the groups after the administration of the tool, which indicates that
both groups equally improved in their knowledge after the implementation of the tool (t= 1.56, NS). However,
data indicated that there was further scope for improvement to attain closer to centum scores in the areas of
weight monitoring, quantity, timings and pattern of fluid consumption that may further enable practicing
adequate hydration behavior.
After implementation of the WOP strategy in the experimental group: After the experimental group
underwent the WOP strategy, T test between the groups revealed that there was a highly significant improvement
(p<0.01) in the knowledge scores of the EG indicating the importance of experiential learning in further
increasing the knowledge and awareness regarding hydration. Therefore the need for implementing a hydration
protocol for athletes as suggested by our formative study, (Kataria et al, 2010) proved to be effective (Table 5).

Table 5: Hydration knowledge after the implementation of WOP strategy

Groups EG
After tool administration 26.75 ± 7.26
After WOP strategy 46.55 ± 0.94
t value 12.08*
*Significant at 0.01 level

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

Table 6: Changes in hydration knowledge of EG after the tool and WOP strategy
Groups Mean difference
Baseline and after tool administration -17.10*
Baseline and after WOP strategy - 36.90*
After tool and after WOP strategy 19.80*
*significant at 0.01 level

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

Table 7: Improvement in hydration knowledge

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

Baseline After tool implementation After WOP strategy

CG EG CG EG EG
0-20% 12 12 0 0 0
20-40% 9 8 7 5 0
40-60% 0 0 10 8 0
60-80% 0 0 3 6 1
80-100% 0 0 0 1 19

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

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

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

Baseline 1.65 ± 1.78 2.60 ± 5.50

After tool implementation 8.55 ± 5.19 9.65 ± 3.51

t value 7.47* 8.54*

*Significant at 0.01 level

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Hydration practices after the WOP strategy

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

Table 9: Hydration practices after the implementation of WOP strategy

Groups EG
After tool administration 9.65 ± 3.51
After WOP strategy 16.75 ± 1.16
t value 8.04*
*Significant at 0.01 level

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

Table 10: Changes in hydration practices of EG after the tool and WOP strategy
Groups Mean difference (I-J)
Baseline and after tool administration - 7.05*
Baseline and after WOP strategy -14.15*
After tool and after WOP strategy - 7.10*
*Significant at 0.01 level

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

Body hydration and PPP:

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

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

Parameter Group Pre Post t-value

Mean ± SD Mean ± SD
HR EG 71.65 ± 8.27 84.65 ± 6.39 14.58*
CG 70.20 ± 7.08 79.4 ± 8.05 7.79*
CRT EG 0.322 ± 0.07 0.49 ± 0.13 7.90*
CG 0.31 ±0.02 0.338 ± 0.01 6.69*
*Significant at 0.01 level

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

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

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

Mean ± SD Mean ± SD
Baseline 71.65 ± 8.27 84.65 ± 6.39 14.58*
Water trial 70.92 ± 8.05 79.62 ± 7.30 -8.72*
Lemonade Trial 73.07 ± 7.95 77.71 ± 6.59 -5.93*
Glucon – D trial 72.35 ± 7.33 75.06 ± 7.55 -6.47*

*Significant at 0.01

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

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

Trials Pre Post t-value

Mean ± SD Mean ± SD
Baseline 0.322 ± 0.07 0.49 ± 0.13 7.90*
Water trial 0.329 ± 0.09 0.357 ± 0.09 -2.73**
Lemonade Trial 0.338 ± 0.082 0.342 ± 0.086 -1.03***
Glucon – D trial 0.345 ± 0.10 0.362 ± 0.13 -1.58 ***
*Significant at 0.01; ** Significant at 0.05; *** Non significant

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

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

Trials Pre Post t-value

Mean ± SD Mean ± SD
Baseline (n=20) 1.016 ± 0.009 1.023 ± 0.006 4.13*
Water trial (n=13) 1.013± 0.01 1.015 ± 0.008 -0.93**
Lemonade Trial (n=14) 1.016± 0.010 1.013 ±0.007 1.60**
Glucon – D trial (n=17) 1.016± 0.009 1.010 ±0.006 3.80*
*Significant at 0.01; ** Non-significant

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

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

Trials Pre Post t-value

Mean ± SD Mean ± SD
Baseline (n=20) 5.88±0.39 5.65±0.48 2.5*
Water trial (n=13) 6 ±0.00 5.85±0.37 1.47**
Lemonade Trial (n=14) 6 ±0.00 5.86 ± 0.36 1.42**
Glucon- D trial (n=17) 6 ±0.00 5.88±0.33 1.46**
*Significant at 0.05
** Non-significant

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

Preparing a BCC based on the holistic module

Our subsequent studies(28,34,35) recognised that nutritional behaviour is framed by a multilayer
process including biological, anthropological, economic, psychological, socio-cultural, and home economics
related determinants and it is shaped by the individual situation (29) and is complex, making behaviour change
also complex. We attempted including all components of behaviour change, that have the ability to assist in
bringing about a conscious change in practices. Many commonly-used theories on behaviour change provide best
information on changes and motivation(30) that are needed to promote healthy behaviour and why, but not on
how changes can be induced.
Thus, the need for a tool for conscious change in the biological process, strengthening the psycho-
physiology/cognition and motivation driven physiological responses prompted us to integrate the ancient Indian
‘Isha Aum’ tool to the erstwhile module and study its effect to assist in bridging the gap between knowledge and
behaviour. The ‘Isha AUM’ tool, described in the Indian veda and offered by Isha Foundation(31) as a tri-
syllable tool using focus, breath and verbal techniques and is claimed as useful in establishing change in
behaviour through psycho-physiological improvement.
To elicit the effect of combining Isha AUM with WOP, in bringing about the necessary change in the
hydration status and psycho-physiology, 18-22 years old male collegiate hockey players, training with the
Government of India were studied with the same research design as our previous study(27b), using WOP as the
controlled intervention and IshaAum WOP as the experimental intervention (Isha Aum was implemented in EG
for 21 days). All physiological, PPP and KAP related parameters were assessed pre and post interventions and
the rating scale assessment-used for spiritual and its related parameters, made.

Changes in body hydration parameters after Isha AUM intervention

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

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Table 16: Changes in body hydration parameters within the EG and CG after Isha AUM
Pre (Mean ± SD) Post (Mean ± SD)
Baseline After Baseline After
Group Paramete measurement intervention t- measuremen intervention t-value
r measureme value t measuremen
nt t

EG 1.024±0.005N 1.013±.005 9.02** 1.026±0.005 1.018±0.009 9.28**

S
USG
CG 1.022±0.004N 1.023±.0005 0.32NS 1.027±0.002 1.027±.004 0.00 NS
S

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

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

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

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

Table 17: Body hydration status of the EG and CG after Isha AUM initiation
Parameter Group Pre (Mean ± SD) t-value Post (Mean± SD) t-value

USG EG 1.013±0.005 4.74** 1.018±0.004 6.19**

CG 1.023±0.005 1.027±0.004

pH EG 6.06±0.175 1.51 NS 5.80±0.414 1.56 NS

CG 5.86±0.480 5.53±0.516

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

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

Changes in Psycho-Physiological Parameters after Isha AUM initiation

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

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

Pre (Mean ± SD) Post (Mean ± SD)

Baseline After Baseline After
Group Parameter measurement intervention t- measurement intervention t-
measurement value measurement value
EG HR 75.33±6.60 66.86±3.99 7.85** 86.80±6.16 79.46±4.95 6.98**
CG 72.66±6.99 71.66±5.23 0.59NS 83.86±9.36 84.86±8.65 0.38NS
EG SRT 0.297±0.01 0.250±0.02 9.15** 0.329±0.02 0.303±0.01 5.48**
CG 0.300±0.02 0.290±0.02 1.93NS 0.329±.02 0.339±0.03 1.86NS
EG CRT 0.426±0.44 0.342±0.04 7.31** 0.520±0.06 0.4141±0.04 8.68**
CG 0.410±0.02 0.400±0.04 0.76NS 0.558±0.03 0.561±0.04 0.29NS
**Significant at .01 level; NS- Not significant

Independent t-test was used to compare post- intervention, psycho-physiological parameters of EG and
CG (Table 19).The data indicated that there was a significant difference for both the pre and post-exercise
psycho-physiological parameters between the EG and CG with improved levels in EG which was perhaps linked
with their improved hydration status after the 21 days implementation of Isha AUM initiation in this group.
To assess if hydration and psycho-physiology are related, the covariance between their parameters was
calculated and since a positive covariance of USG and pH with SRT and CRT was observed, it indicates that the
dehydration may be the reason for no change of psycho-physiological parameter in CG. Our previous studies
have also indicated a positive covariance between USG and HR, and concluded that dehydration may have led to
deterioration in the psycho-physiological profile particularly the HR(26, 26b) and this was supported by data of
this study.

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

Parameter Group Pre (Mean ± SD) t-value Post (Mean± SD) t-value
HR EG 66.86±3.99 2.82** 79.46±4.95 2.09**
CG 71.66±5.23 84.86±8.65
SRT EG 0.250±0.02 5.60** 0.303±0.01 4.01**
CG 0.290±0.02 0.339±0.03
CRT EG 0.342±0.04 3.58** 0.4141±0.04 7.43**
CG 0.400±0.04 0.561±0.04

** Significant at .01 level

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

Implementation of the rating scale to assess the changes in practices related to

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

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

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

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

Baseline scores
Parameters t-value

EG CG
Hydration practices
Fluid consumption before exercise 3.13 ±0.915 2.8 ±0.836 0.43 NS
Fluid consumption during exercise 2.40 ± 1.140 2.8± 0.547 0.63 NS
Fluid consumption after exercise 4.80± 0.836 4.8±0.0.836 0.31 NS
Perceived positive parameters
Happiness 7.13 ± 1.355 7.33 ± 1.046 0.45NS
Calmness 5.80 ± 1.082 6.00 ± 1.253 0.46 NS
Concentration 6.20 ± 1.207 6.40 ± 1.183 0.45 NS
Awareness regarding thirst 4.00 ± 0.925 3.86 ± 0.743 0.43NS
Sports Performance 6.60 ± 0.828 6.60 ± 0.728 0
Perceived negative parameters
Stress 6.46 ± 1.355 6.20± 1.420 0.64 NS
Fatigue 4.40 ± 1.594 4.80 ± 1.521 0.70 NS
Anger 5.20 ± 1.320 5.66 ± 1.397 0.94 NS
NS: Non significant

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

Table 21: Differences in perceived parameters

Parameters After intervention
Group Baseline scores Scores t-values
Hydration practices
Fluid consumption before exercise EG 3.13 ±0.915 7.73±0.883 12.68**
CG 2.8 ±0.836 5.0±0.707 3.31*
Fluid consumption during exercise EG 2.40 ± 1.140 7.20±0.447 8.23**
CG 2.8± 0.547 3.40±0.836 2.44 NS
Fluid consumption after exercise EG 4.80± 0.836 8.40±0.547 14.69**
CG 4.8±0.0.836 5.20±0.447 0.78 NS
Perceived positive parameters
Happiness EG 7.13 ± 1.355 7.80 ± 1.041 3.56**
CG 7.33 ± 1.046 7.13 ± 1.187 0.71 NS
Calmness EG 6.00 ± 1.253 8.133 ± 0.833 10.0**
CG 6.00 ± 1.253 5.866 ± 1.457 0.80 NS
Concentration EG 6.20 ± 1.207 8.06 ± 0.798 7.89**
CG 6.40 ± 1.183 6.40 ± 1.121 0
Awareness regarding thirst EG 4.00 ± 0.925 7.80 ± 0.861 14.51**
CG 3.86 ± 0.743 4.46 ± 1.187 2.80 NS
Sports Performance EG 6.60 ± 0.828 7.13 ± 0.915 3.28**
CG 6.60 ± 0.728 6.80 ± 1.014 1.14 NS
Perceived negative parameters
EG 6.46 ± 1.355 4.66 ± 0.975 6.08**
Stress CG 6.200 ±1.42 6.66 ±1.112 1.97 NS
EG 4.40 ± 1.594 4.00 ± 1.309 2.44*
Fatigue CG 4.80 ±1.521 4.46 ±1.302 1.435 NS
EG 5.20 ± 1.320 4.06 ± 1.099 5.90**
Anger CG 5.66 ±1.397 5.266 ±1.22 1.702 NS
** Significant at .01 level; * Significant at .05 level ;NS: Non significant

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

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

Parameters After intervention scores

t-value

EG CG
Hydration practices
Fluid consumption before exercise 7.73±0.883 5.0±0.707 5.71**
Fluid consumption during exercise 7.20±0.447 3.40±0.836 10.87**
Fluid consumption after exercise 8.40±0.547 5.20±0.447 10.11**
Positive parameters
Happiness 7.80±1.041 7.13 ± 1.187 1.65NS
Calmness 8.13±0.833 5.86 ± 1.457 5.22 **
Concentration 8.06 ± 0.798 6.40 ± 1.121 4.68 **
Awareness regarding thirst 7.80 ± 0.861 4.46 ± 1.187 8.80**
Negative parameters
Stress 4.66 ± 0.975 6.66 ±1.112 5.23**
Fatigue 4.00 ± 1.309 4.46 ± 1.302 0.97 NS
Anger 4.06 ± 1.099 5.266 ±1.22 2.82**
** Significant at 0.01; NS: Non significant

This indicated that Isha AUM initiation brought improvement in various practices in EG which was the
reason for their enhanced hydration status and thus psycho-physiology. Also, that such tools have several added
benefits on physical(improved HR, lower stress levels ); Mental (GSR, SRT, CRT, focus, concentration);emotional
(Calm or peace, sense of well being, less anger, improved relations) and Energy(Energetic, lighter, efficient)
parameters. Integrated enhancement of these parameters naturally aids in maximal athletic performance – the ultimate
goal of all training, hence, tools such as Isha AUM may be useful in enhancing the inner potential of the athlete to
make necessary changes in his lifestyle, to support improved hydration as well as improved sports performance.
In conclusion, our studies(26, 26b, 27, 28, 34, 35) indicate that exercise and heat induced subtle
dehydration, may affect PPP and including ancient tools such as Isha AUM to the erstwhile strategies helps bring
out the necessary change in hydration behaviour. Further, since Isha AUM is described as an ancient Indian tool
used in spirituality and yoga, the spiritual component of health, as proposed by WHO(32,33)may be the missing
link between awareness, intention and empowerment to change.

References:
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Perspectives in exercise science and sports medicine, Vol. 3.Fluid homeostasis during exercise. C.V Gisolfi and
Lamb DL. Benchmark Press, Inc, 1990: 129-180.
2. Valentine V. The Importance of Salt in the Athlete's Diet. Current Sports Medicine Reports 2007;6
(4):237-240.
3. Maughan RJ, Shirreffs SM. Dehydration and rehydration in competitive sport. Scandinavian Journal of
Medicine & Science in Sports 2010;20(3):40-47.
4. Murray R. Hydration and physical performance. J Am Coll Nutr. 2007;26:542S-548S.
5. Paik IY, Jeong MH, Jin HE, et al. Fluid replacement following dehydration reduces oxidative stress
during recovery. Biochem Biophys Res Commun. 2009 22;383(1):103-7.
6. Yuko T, Kazuhiro S, Kai T, et al. Exercise-Induced Oxidative DNA Damage and Lymphocytopenia in
Sedentary Young Males. Medicine and Science in Sports and Exercise 2008;40(8)1455-1462.
7. Sharp RL. Role of sodium in fluid homeostasis with exercise. J Am Coll Nutr 2006;25 :231S –239S.
8. Montain SJ. Hydration Recommendations for Sport. Current Sports Medicine Reports 2008;7(4):187-192.
9. Dougherty KA, Baker LB, Chow M, Kenney WL. Two percent dehydration impairs and six percent
carbohydrate drink improves boys basketball skills. Med Sci Sports Exerc. 2006;38:1650 –1658.
10. Rehrer NJ, Burke LM. Sweat losses during various sports. Aust J Nutr Diet 1996;53:S13 –S16.

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

11.Murray R. Hydration and physical performance. J Am Coll Nutr. 2007;26:542S- 548S, 2007;
12.Passe DH, Horn M, Stofan J, Horswill C, Murray R. Voluntary dehydration in runners despite
favorable conditions for fluid intake. Int J Sport Nutr Exerc Metab. 2007 ;17(3):284-95.
13. Greenleaf JE. Problem: thirst, drinking behavior, and involuntary dehydration. Med Sci Sports Exerc
1992;24 :645 –656.
14 Pitts GC, Johnson RE, Consolazio FC: Work in the heat as affected by intake of water, salt and
glucose. Am J Physiol 1944;142 :253 –259.
itts et al, 1944). )
15 Osterberg KL, Pallardy SE, Johnson RJ, Horswill CA. Carbohydrate exerts a mild influence on fluid
retention following exercise-induced dehydration. J Appl Physiol 2010;108:245-250.
16. Rodriguez NR, DiMarco NM, Langley S. Position of the American Dietetic Association, Dietitians of
Canada, and the American College of Sports Medicine: Nutrition and athletic performance. J Am Diet
Assoc. 2009;109(3):509-27.
17 Singh R. Nutritional requirements of athletes exercising in a hot environment.Mal J Nutr.2005; 11(2):
189-198.
18.Singh R, Saat M, Sirisinghe RG, Nawawi M. Rehydration with fresh young coconut water,
carbohydrate-electrolyte beverage and water following exercise-induced dehydration. Can J Appl Physio
2001;2:267-268.
19 Thomas R, Barry D, Warren G. Thermoregulation in elite athletes. Current Opinion in Clinical
Nutrition & Metabolic Care 2006;9(6):666-671.
20 Lorenzo S, Halliwill JR, Sawka MN, Minson CT. Heat acclimation improves exercise performance. J
Appl Physiol. 2010;109(4):1140-7.
21. Indian Council of Medical Research. Nutrient requirements and Recommended Dietary Allowances
for Indians. A Report of the Expert group of ICMR 2010.
22 Hydration guidelines for excellence in sports performance. National Institute of Nutrition, International
Life Sciences Institute of India, Sports Authority of India, 2006.
23. Armstrong LE, Maresh CM. Fluid replacement during exercise and recovery from exercise. Body
Fluid Balance: Exercise and Sport. New York, NY: CRC Press; 1996:259 –281.
24. American College of Sports Medicine. ACSM Position Stand on Exercise and Fluid Replacement.
Med Sci Sports Exerc 2007;39:377-390.
25. Casa DJ, Armstrong LE, Hillman SK, et al. National Athletic Trainer’s Association Position
Statement: Fluid Replacement for Athletes. J Athl Train 2000:35(2):212-224.
25.Lal P R.Nutritional Requirements for Sports Persons, Journal of Indian Dietetic Assoc 2006;31,1-7.
26.Kataria I, Sahni S, Lal PR. Effect of body hydration status on the psycho-physiological profile of
college level women basketball players(18-22 years). British journal of Sports Nutrition 2010; 44 (suppl I).
26b.Kataria I, Lal P R, Sahni S. Effect of hydration status on psychophysiological profile of athletes.
Lambert Academic Publications, Germany 2012 ISBN 978 – 3 – 659 – 11181 – 5 (book168 pages).
27.Oberoi A, Lal P R, Effect of hydration with three popular fluids on the psychophysiology of collegiate
women basketball players. Proceedings of ISSN,Sep27-30 Kualalumpur 2010 Malaysia(abstract).
27b.Oberoi A, Lal P R. Effect of a fluid replacement strategy on the hydration status and
psychophysiology of collegiate(18-22years) basketball players. Proceedings of the annual meeting of the Indian
Dietetic Association, Sep 2011(full article).
27c.Wadhwa E and Lal P R. Effect of hydration status and psychophysiological parameters on the injury
status of athletes. M.Sc. thesis, department of Food and Nutrition, Lady Irwin College.2012(unpublished).
28.Aggarwal A, Lal P R. Education with Isha Aum in the improvement of psychophysiology and
hydration practices of athletes. July 2012, Book Published by Lambert Academic Publication.
29 Gedrich K. Determinants of nutritional behaviour: a multitude of levers for successful intervention.
Research Report 25th anniversary Symposium of AGEV 2003;41:231-238.
30. Brug J, Oenema A, Ferreira I. Theory, evidence and intervention mapping to improve behaviour
nutrition and physical activity interventions. International journal of Behavioural Nutrition and Physical Activity
2005;2.
31.Vasudev SJ. Mystic’s Musings. 1st ed. Wisdom Tree Press, 2007.
32.WHO. Ottawa Charter for Health Promotion, adopted by the International Health Promotion
Conference, Ottawa, 21 November, 1986.
33. ϋstϋn B, Jakob R. Re-defining ‘Health’. Bulletin World Health Organisation 2005;83:802.
34. Aggarwal A, Lal P R. Effect of Isha Aum on the psychophysiology and hydration practices of
athletes. Proceedings of the annual meeting of the Indian Dietetic Association, Sep 2012(full article).
35. Priti Rishi Lal, Aanchal Agarwal and Bhavani Balakrishnan. Nutrition education with Isha Aum and
improvement in psychophysiology, hydration status and hydration practices of collegiate hockey players.Paper
presented at the Food Studies Conference, University of Illinois, Urbana Champaign, USA

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Applications of salivary biomarker measures in sport

science

McKune A. J.
Discipline of Biokinetics, Exercise and Leisure Sciences, University of KwaZulu-Natal, Durban, South Africa

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

Sport Science and Saliva Biomarkers

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

Monitoring Mucosal Immunity

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

Monitoring Salivary Hormones

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

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Importantly, measurement of salivary hormones may be a promising for talent identification

programmes as indicated through the findings of a recent study by Cook et al. (2012). The authors found that
salivary measurement of testosterone was effective in differentiating between elite and non-elite female athletes
(young adults). Specifically, baseline free testosterone concentrations of a mixed group of elite female athletes
were consistently more than double (112% higher) than those of a comparative non-elite group over a prolonged
period of training and competition (10). Higher baseline testosterone may indicate a greater capacity for
performance at higher work rates, which is commensurate with the demands of elite sport and a greater
motivation to train. In addition, the link between testosterone and sporting potential could be mediated by
behavioral mechanisms. Previous work identified that female testosterone levels are related to risk aversion (a
possible indicator of competitiveness) (11), and to self-reported dominance (12), with high testosterone females
also achieving higher dominance scores than those with lower testosterone (13). Arguably, the expression of
dominance-related behaviors in sport may help to differentiate elite from non-elite athletes. Further research is
required to examine the efficacy of measuring salivary hormones as part of talent identification programmes in
younger individuals.
Research has also shown the importance of the salivary testosterone response to training workouts in
predicting subsequent performance in professional rugby league competition (14). Specifically, the authors
demonstrated that hormone response to a mid-week workout provided an early sign of team readiness to compete
as well as recovery rate. Measurement of the salivary hormone response to training may therefore be a novel
method for implementing training or management strategies to improve competition outcomes.
Measurement of salivary hormones has also been shown to be useful for examining the effects of
different pre-match motivational interventions and post-match recovery interventions on subsequent athlete
game performance (15, 16). Specifically, presentation of specific video footage combined with different coach
feedbacks influenced free hormonal state and game performance several days later. Finally, the presentation of
short video clips can be used to alter salivary testosterone concentrations as well as subsequent voluntary squat
performance. Specifically, relative changes in testosterone concentration differed depending on the video-clip
shown to athletes pre-workout. These changes were then demonstrated to modulate behavioural aspects and
athlete performance (17).

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

References
1. McKune AJ, Du Bose K. Relationship between salivary androstenedione, body composition and physical
activity in young girls. Journal of Endocrinology, Metabolism and Diabetes of South Africa.
2012;17(1):44-50.
2. McKune AJ, Smith LL, Semple SJ, Wadee AA, Fickl H, Villa JG, et al. Changes in mucosal and humoral
atopic-related markers and immunoglobulins in elite cyclists participating in the Vuelta a Espana. Int J
Sports Med. 2006 Jul;27(7):560-6.
3. Caruso JF, Lutz BM, Davidson ME, Wilson K, Crane CS, Craig CE, et al. Salivary hormonal values from
high-speed resistive exercise workouts. J Strength Cond Res. 2012 Mar;26(3):625-32.
4. Koka S, Beebe TJ, Merry SP, DeJesus RS, Berlanga LD, Weaver AL, et al. The preferences of adult
outpatients in medical or dental care settings for giving saliva, urine or blood for clinical testing. J Am
Dent Assoc. 2008 Jun;139(6):735-40.
5. Mackinnon LT. Immunoglobulin, antibody, and exercise. Exerc Immunol Rev. 1996;2(1-35).
6. van Egmond M, Damen CA, van Spriel AB, Vidarsson G, van Garderen E, van de Winkel JG. IgA and the
IgA Fc receptor. Trends Immunol. 2001 Apr;22(4):205-11.
7. Neville V, Gleeson M, Folland JP. Salivary IgA as a risk factor for upper respiratory infections in elite
professional athletes. Med Sci Sports Exerc. 2008 Jul;40(7):1228-36.
8. Fahlman MM, Engels HJ. Mucosal IgA and URTI in American college football players: a year
longitudinal study. Med Sci Sports Exerc. 2005 Mar;37(3):374-80.

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9. Mortatti AL, Moreira A, Aoki MS, Crewther BT, Castagna C, de Arruda AF, et al. Effect of competition
on salivary cortisol, immunoglobulin A, and upper respiratory tract infections in elite young soccer
players. J Strength Cond Res. 2012 May;26(5):1396-401.
10. Cook CJ, Crewther BT, Smith AA. Comparison of baseline free testosterone and cortisol concentrations
between elite and non-elite female athletes. Am J Hum Biol. 2012 Nov-Dec;24(6):856-8.
11. Sapienza P, Zingales L, Maestripieri D. Gender differences in financial risk aversion and career choices
are affected by testosterone. Proc Natl Acad Sci U S A. 2009 Sep 8;106(36):15268-73.
12. Sellers JG, Mehl MR, Josephs RA. Hormones and personality: testosterone as a marker of individual
differences. J Res Pers. 2007;41(126-138).
13. Grant VJ, France JT. Dominance and testosterone in women. Biol Psychol. 2001;58:41-7.
14. Crewther BT, Sanctuary CE, Kilduff LP, Carruthers JS, Gaviglio CM, Cook CJ. The workout responses of
salivary-free testosterone and cortisol concentrations and their association with the subsequent competition
outcomes in professional rugby league. J Strength Cond Res. 2013 Feb;27(2):471-6.
15. Cook CJ, Crewther BT. The effects of different pre-game motivational interventions on athlete free
hormonal state and subsequent performance in professional rugby union matches. Physiol Behav. 2012 Jul
16;106(5):683-8.
16. Crewther BT, Cook CJ. Effects of different post-match recovery interventions on subsequent athlete
hormonal state and game performance. Physiol Behav. 2012 Jun 25;106(4):471-5.
17. Cook CJ, Crewther BT. Changes in salivary testosterone concentrations and subsequent voluntary squat
performance following the presentation of short video clips. Horm Behav. 2012 Jan;61(1):17-22.

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The eye in sporting activities

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

General physicians and sports physicians will often be the first contact with patients regarding sports,
and ophthalmologists only see the patient when referred. Hence, it is hoped that this talk would be informative
and useful in optimising eye care for patients.
When we talk about sporting activities, we mean physical exertion usually outdoors. Therefore, when
someone does physical exertion such as in dancing, playing certain musical instruments, gardening or physical
work, the following may also apply.
This talk will be divided into 3 sections:
(A) Ophthalmic conditions that may have implications for sporting activities
(B) Healthy eye and sporting activities
(C) Eye injuries in sporting activities.

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

1. Evolving posterior vitreous detachment:
A patient who complains of recent flashes/floaters should be examined by an ophthalmologist for retinal
tears, holes and detachment, and advised to avoid jerky head movements until the flashes settle. Hence, as there
are usually jerky head and eye movements in sporting activities, it should be avoided. Reading a book may also
cause jerky eye movements due to saccades when scanning the page, and hence, should be minimised or avoided.
When young, the vitreous is attached to the retina. With age, the vitreous may shrink and move forward,
and so causes traction on the retina. This can result in retinal tear and hole formation in a small percentage of
cases.
The retina is like a wallpaper attached to the inside of the globe with hydrostatic pressure and vacuum.
When there is a break in the retina, fluid enters the subretinal space and this then leads to retinal detachment.
Jerky head movements increase vitreo-retinal traction, and hence, increases the risk of retinal hole
formation.
2. Recent intraocular surgery:
In cataract surgery, the wound is usually sutureless now. Putting pressure on the corneal wound edges
may cause the wound to open and leak aqueous. Hence, it is important to prevent blunt trauma or rubbing the eye
for a few weeks, as this may open the surgical wound.
In glaucoma surgery, a fistula is created to allow aqueous to drain from the anterior chamber to the
space and tissues between the conjunctiva and sclera. In the first few weeks, putting pressure on the eyeball may
cause too much fluid to drain out. It is important to avoid activities that may raise intraocular pressure such as
pressing on the eyeball, forcible lid closure, weight lifting, wearing small swimming goggles, etc.
There is usually associated posterior vitreous detachment. Hence, it is important to avoid jerky head and
eye movements as well.
3. Glaucoma and excessive water drinking:
After exercise, one usually feels thirsty due to loss of water through perspiration. Hence, there is a desire
to drink a large volume of water. When one drinks more than 2 glasses of water (500 ml) within an hour, there is
a risk of causing intraocular pressure rise, especially in a patient who has glaucoma.
Hence, advise glaucoma patients not to drink more than 2 glasses of water in an hour, ie spread or space
out the water intake.
4. Glaucoma surgery and swimming:
In glaucoma surgery, a fistula is created to drain the aqueous from the anterior chamber to under the
conjunctiva (that is subconjunctival tissue). Sometimes, the conjunctiva can be quite thin. This means that the

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barrier between the inside of the eye and the outside world is the thin conjunctiva, rather than sclera and
conjunctiva or cornea.
Hence, if a patient who has a thin filtration bleb after glaucoma surgery swims in water that has a
significant bacterial count and gets a bacterial conjunctivitis, this can potentially lead to endophthalmitis which
can be a devastating infection of the eye.
5. Swimming goggles and Glaucoma:
Morgan et al (2008) and Ma et al (2007) reported the rise of intraocular pressures when wearing small
swimming goggles. Hence, swimming goggles should be over the orbital margin and not press on the eye or
eyelid tissue within the orbital margin.
6. Yoga and Glaucoma:
During Yoga head stands, the intraocular pressure can rise two-fold. Baskaran et al (2006) and Gallardo
et al (2006) reported on the rise of intraocular pressure and progression of glaucoma with Sirsasana (head stand)
yoga posture. This is probably due to increased episcleral venous pressure and increased choroidal volume from
vascular engorgement. Hence, advise patients with glaucoma to avoid yoga head stands.
7. Herpes simplex keratitis and UV light
When the Herpes Simplex virus infects the cornea, the virus can become a chronic problem. The virus
can remain inactive for many years and UV light can reactivate the virus. Hence if a patient who has a history of
herpes simplex keratitis, spends a lot of time outdoors in the sun playing sports, there is a risk that it may
contribute to recurrent herpes simplex keratitis.
8. Acute conjunctivitis and swimming
Viral conjunctivitis can be spread by tears. If patients with viral conjunctivitis contaminate their fingers
with their tears and then touch door knobs, other people who touch the door knobs and then their eyes can
transfer the virus to their eyes.
Patients with acute conjuncitivitis, especially viral and Chlamydia may contaminate the water in a
swimming pool. This can be contagious to other users of the swimming pool.

(B) Healthy eye and sporting activities

1. Sore eyes after swimming – use tear supplements or wear goggles
The tear film consists of 3 layers – lipid, aqueous and mucin layers. It has electrolytes and other
components that help to keep the pH constant. When swimming, the ocular surface is bathed with swimming pool
water which may be of a different pH besides containing chlorine. This can cause ocular irritation. To help this
problem, the use of tear supplements can be used before and after swimming. Taking omega-3 flax seed or fish
oil can also help improve the tear film.
If pool water is not well maintained, the water may harbour bacteria and viruses. Hence, may need to use
topical antibiotics (Chloromycetin, Tobrex) if acute conjunctivitis is present.
2. Avoid or minimise UV light exposure – Ultraviolet light may contribute to pterygium/pingueculae
and cataract formation and also macular degeneration. Hence, wear sunglasses, and avoid sun exposure around
midday. We should be aware of additional exposure due to reflected light from snow in skiing and from water in
water sports.
3. Wear eye protection, especially if they have only one good eye, ie the other eye blind or amblyopic.
Eye injuries may occur when least expected. Certain sports such as squash may have a higher risk of eye injury.
4. Contact lenses versus glasses for sporting activities. Glasses may be better as they may protect the eye
from blunt trauma or dust. If a tennis ball or badminton shuttlecock hits the eye, the eye can sustain significant
blunt trauma. In someone who wears glasses, the spectacles would take some of the impact and may transmit
some of the forces to the nose and cheek. This will probably cause bruising, rarely a fracture. If the spectacle
lenses break, the broken glass or plastic may cut the eye; but it would be less traumatic than a severe blunt trauma
causing a rupture of the globe.
5. Patients with poor tear film, may get stingy eyes if sweat gets into the eyes as the sweat has a different
composition and pH to tears. Lid hygiene may help. Omega 3 fish oil or flaxseed oil can improve the tear film
and improve the buffering properties, and thus prevent this problem.
6. Mountaineering and High Altitude Retinopathy:
Mountaineers who climb over 5,000 metres above sea level may get retinal haemorrhages (High Altitude
Retinopathy). Barthelmes et al (2011) and Wiedman and Tabin (1999) described the appearance of retinal
haemorrhages in altitudes above 5000m. If the retinal haemorrhages occur over the macula, vision may be
compromised.

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(C) Eye injuries in sporting activities

When assessing a patient with acute ocular trauma, it is important to routinely check and record visual
acuity besides looking for the physical signs of eye injury. Besides the eye, the eyelids and orbit may also sustain
trauma. Orbital floor blowout fractures usually cause restriction of eye movements and bruising of periorbital
tissue. Hence, it is important to check for ocular movements and integrity of eyelid tissue.
Macewen (1987) did a survey of sport associated eye injury in a casualty department in Glasgow Eye
Infirmary, which described injuries from football, rugby, squash, badminton, skiing and other sports.
1. Corneal-conjunctival abrasions – corneal and conjunctival abrasions can result from contact
with the ball, racquet or finger. Fluorescein staining shows up corneal or conjunctival epithelial defects. A
sharp edge may cause corneal or conjunctival lacerations or even a penetrating eye injury. A full thickness
penetrating injury can cause iris prolapse with the iris plugging the hole. Conjunctival-subconjunctival
haemorrhage may also be present.
2. Corneal wound and iris prolapse – we can evaluate for this by looking for any black tissue
protruding from the cornea or conjunctiva-sclera. If there is iris prolapse,, the pupil is usually not circular,
probably peaked at one edge.
3. Hyphaema – hyphaema may be microscopic or macroscopic. The blood may come from torn
iris or uveal tissue. Initially the aqueous is mixed with blood and hence, one sees a hazy view of the pupil
and iris. When the blood settles, then one can see the blood level. The slit lamp microscope is needed to
evaluate for microscopic hyphaema.
4. Traumatic iritis: This is common after a blunt injury. There is low grade iritis, and may be
associated with traumatic mydriasis.
5. Traumatic mydriasis - The sudden stretching of iris can paralyse the sphincter pupillae. Usually
it takes a few days to recover. However, if there is actual tearing of iris sphincter, then pupil constriction
may be compromised in the future and pupils may be unequal in size.
6. Traumatic iridodialysis – sudden compressive force of the eyeball anterior-posteriorly, causes
stretching-expansion around the equator, and this can tear the iris at its root causing iridodialysis. There is
usually associated hyphaema and the iris-pupil is out of shape.
7. Acute glaucoma - this may be associated with hyphaema. The red blood cells block the
trabecular meshwork, and restricts aqueous outflow; hence a rise of intraocular pressures.
8. Scleral rupture – this usually appears as black tissue in the white of the sclera. However, it can
be difficult to evaluate for this if there is significant conjunctival and subconjunctival haemorrhage.
Posterior scleral rupture may be difficult to detect
9. Damage to Lens and Zonules - In significant blunt trauma, zonules may be torn and this can
cause phacodenesis or lens dislocation-subluxation. Cataracts may also form after trauma to the lens.
10. Retinal oedema and haemorrhage - Shock waves to the retina can cause commotio retinae.
There is retinal oedema and a relative scotoma may be present on visual field testing. Vitreoretinal traction
may cause retinal haemorrhage and retinal tear-hole-detachment formation.
There is risk of expulsive haemorrhage in severe blunt trauma especially if there is prolonged hypotony
after rupture of the globe. Sudden haemorrhage pushing out the contents of eye (retina and uvea) through wound
in sclera or cornea, makes salvaging the eye not possible. Sympathetic ophthalmia is rare and can occur after
severe trauma. The severely injured eye is usually blind, and the patient complains of glare and pain in the good
uninjured eye. This is due to auto-immune induced inflammation by antigens released from the injured eye.
There may be long term possibility of glaucoma due to damage to trabecular meshwork if angle
recession is present. Stretching of the tissues of the trabecular meshwork can lead to scarring. When young the
trabecular meshwork is efficient, so if 50% of the trabecular meshwork is scarred, the efficient other 50% may be
sufficient. With age, especially when there is a tendency or family history of glaucoma, the trabecular meshwork
can become less efficient, and hence, the remaining 50% becomes insufficient and so intraocular pressure rises.
Unilateral glaucoma can be due to previous trauma.

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

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References:
Barthelmes D, Bosch MM, Merz TM, Petrig BL, Truffer F, Bloch KE, Holmes TA, Cattin P, Hefti U, Sellner M,
Sutter FK, Maggiorini M, Landau K (2011): Delayed Appearance of High Altitude Retinal Hemorrhages.
Plos one: www. Plosone.org. February 2011, Volume 6, Issue 2.
Baskaran M, Raman K, Ramani KK, Roy J, Vijaya L, Badrinath SS (2006): Intraocular pressure changes and
ocular biometry during Sirsasana (headstand posture) in yoga practitioners. Ophthalmology, 2006 Aug;
113 (8): 1327-1332.
Gallardo MJ, Aggarwal N, Cavanagh HD, Whitson JT (2006): Progression of glaucoma associated with the
Sirsasana (headstand) yoga posture. Adv Ther. 2006 Nov-Dec; 23 (6) 921-925.
Ma KT, Chung WS, Seo K, Seong GJ, Kim CY (2007): The effect of swimming goggles on intraocular pressure
and blood flow within the optic nerve head. Yonsei Med J 2007 Oct 31; 48 (5) , 807-809.
Macewen CJ (1987): Sport Associated eye injury: a casualty department survey. British Journal of
Ophthalmology, 1987, 71, 701-705.
Morgan WH, Cunneen S, Balaratnasingam C, Yu DY (2008): Wearing swimming goggles can elevate intraocular
pressure. Br J Ophthalmolol 2008, 92, 1218-1221.
Wiedman M, Tabin GC (1999): High-altitude retinopathy and altitude illness. Ophthalmology 1999 Oct; 106
(10) 1924-1926.

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Platelet-rich plasma: Facts and fallacies.

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

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

Table 1: Growth factors in the α-Granules of platelets and their physiologic effect*
Growth factors Biologic activities
TGF-β Promotes matrix synthesis
PDGF Chemoattraction, cell proliferation
IGF-I, II Cell proliferation, maturation, bone matrix synthesis
FGF Angiogenesis, fibroblasts proliferation
EGF Cell proliferation
VEGF Angiogenesis
ECGF Endothelial cell proliferation, angiogenesis

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

The two common methods of PRP preparation are the plasma-based and the buffy-coat based systems.
Each method produces PRP that differs in quality including the amount of platelets, white blood cells (WBC)
and growth factors [3].
Mishra et al, proposed a PRP classification systems that is based on its cellular contents [4].
PRP have been used in medicine since 1970 in various discipline including maxillofacial surgery, dental
implant, plastic surgery, orthopaedic, rheumatology and tissue engineering [5]. In the field of Sports Medicine,
PRP used received a lot of attention after it was reported to have successfully used in treating knee ligament
injury of two NFL professional players in 2009. Both players were allowed to return-to-play within 6 weeks [6].
Since then, several high profiles professional athletes were reported using PRP for their injuries.
Autologous blood and blood products including autologous condition serum (ACS), platelet rich plasma
(PRP) and platelet-rich in fibrin matrix (PRFM) are currently used for their potential benefits in accelerating soft
tissues healing (tendons, muscles and ligaments) despite limited clinical evidence [7].
Our literature review found effects of PRP were frequently studied on tendinopathies, including tennis
elbow, Achilles and patellar tendinopathies.
In a cohort study of patient with long standing elbow pain (mean of 15 months) that failed to show any
improvement with non-operative treatment. Patient who received PRP injection demonstrated significant
improvement in their visual analog pain scores eight weeks after the intervention [8].
Since then several randomised controlled trial (RCT) has been conducted, that consistently
demonstrated positive effects of PRP injections (Table 2).
More recently, a multicentre double blind RCT of 230 patients found patient treated with PRP showed
significant improvement in pain score at 8 and 12 weeks. More over clinically success rates as measured by a ≥
25% reduction in pain score over baseline, were found in PRP treated patient at 24 weeks (p=0.012) [9].

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Only two RCTs explored the effects of PRP on Achilles tendinopathy (Table 2). The findings of these
studies was less consistent, with each demonstrated significant and non-significant effects of PRP on the
outcomes measures. Furthermore no RCT is currently available on the effect of PRP on patellar tendinopathy.
Only one pilot controlled trail of PRP on muscle healing was available at the time of this review [10].
The study was a non-randomised and non-blinded trial of professional athletes diagnosed with acute
second-degree muscle injury. Intervention group received ACS 2.5 ml of ACS injection administered every
second day (mean 5.4 injections/athlete) until full recovery was achieved. Even though this study found a
significant reduction in DRP among athletes treated with ACS (16.6±0.9 days vs. 22.3±1.2 days, p=0.001), the
study design has been question [7,11,12] as it lacks robustness that may restricts interpretation of the findings
with low methodological quality score [13].
More recently, a retrospective case control study of ten professional National Football League athletes
with grade-I and-II muscle injuries reported no significant difference in the duration to RTP between PRP treated
and control groups [14]. The design of the study and small number of patients participated in the study may
affect on the generalizability of this study.
The efficacy of PRP therapy on soft tissue healing in humans remained unanswered. Currently there is
some evidence to suggest beneficial effects of PRP for treating tennis elbow and acceleration of muscle
recovery. However, the PRP effect on other tendinopathies is less evident.

Table 2: PRP studies on tendinopathies

Author Design Intervention Outcome Findings
Tennis elbow
Mishra & Pavelko, Cohort PRP injection VAS score Significant pain reduction
2006 study vs. Modified Mayo
Bupivacaine elbow score
injection
Peerbooms et al., RCT PRP injection VAS score Significant pain reduction
2010 vs. DASH score and better functional
Corticosteroid score
injection
Thanasas et al., RCT PRP injection VAS score Earlier pain relief (6
2011 vs. Liverpool elbow weeks),
AB injection score No difference – long term
Creaney et al., 2011 RCT PRP injection PRTEE Equally effective in
vs. reducing PRTEE score
AB injection
Achilles tendinopathy
Gaweda et al., 2010 Case series PRP injection AOFAS score Significant improvement
VISA-A score in all outcome measures
US appearance
de Vos et al., 2010 RCT PRP injection VISA-A score No significant difference
vs. Patient satisfaction
Saline injection
de Almeida et al., RCT PRP injection VAS score Improve pain score
2010 vs. MRI appearance immediately but no
No injection difference long term
Patellar tendinopathy
Kon et al., 2009 Case PRP + physiotherapy Tegner No significant difference
control vs. EQ-VAS
Physiotherapy SF-36
Filardo et al., 2009 Case series PRP injection Tegner Significant improvement
EQ-VAS from baseline
SF-36
VAS, visual analog scale; RCT, randomised controlled trial; DASH, disability of arm, shoulder and hand; AB, autologous
blood; PRTEE, patient-related tennis elbow evaluation; AOFAS, American Orthopedic Foot and Ankle Society; VISA-A,
Victorian Institute of Sport Assessment-Ankle; US, ultrasound; MRI, Magnetic resonance imaging; EQ-VAS, EuroQol Visual
analog scale; SF-36, Short form-36.

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It should be reminded that currently available studies vary in their methodology; including type of
injectable substance use (ACS, PRP and PRFM), preparation of injectable substance, dosages, frequency of
injections, type of muscle injury and the follow-up period.
Developing and adopting a standardised method of PRP classification, treatment protocol and outcome
measures assessments are imperative to allow accurate comparisons between studies.
Therefore the current evidence is insufficient to recommend for or against routinely using PRP in
muscle injury. Studies using robust clinical design are needed to evaluate the efficacy of PRP for the treatment
of muscle injury.

References:
1. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA (2009) Platelet-Rich Plasma: From
Basic Science to Clinical Applications. Am J Sports Med 37: 2259–2272.
2. Hammond JW, Hinton RY, Curl LA, Muriel JM, Lovering RM (2009) Use of autologous platelet-rich
plasma to treat muscle strain injuries. Am J Sports Med 37: 1135–1142.
3. DeLong JM, Russell RP, Mazzocca AD (2012) Platelet-Rich Plasma: The PAW Classification System.
YJARS 28: 998–1009. doi:10.1016/j.arthro.2012.04.148.
4. Mishra A, Harmon K, Woodall J, Vieira A (2012) Sports medicine applications of platelet rich plasma.
Curr Pharm Biotechnol 13: 1185–1195.
5. Anitua E, Andí I, Sanchez M, Azofra J, del Mar Zalduendo M, et al. (2006) Autologous preparations rich
in growth factors promote proliferation and induce VEGF and HGF production by human tendon cells in
culture. J Orthop Res 23: 281–286. doi:10.1016/j.orthres.2004.08.015.
6. nytimes.com (n.d.) nytimes.com. Available: http://www.nytimes.com. Accessed 28 January 2013.
7. Engebretsen L, Steffen K, Alsousou J, Anitua E, Bachl N, et al. (2010) IOC consensus paper on the use of
platelet-rich plasma in sports medicine. Bri J Sports Med 44:1072–1081.
8. Mishra A, Pavelko T (2006) Treatment of Chronic Elbow Tendinosis With Buffered Platelet-Rich Plasma.
American Journal of Sports Medicine 34: 1774–1778. doi:10.1177/0363546506288850.
9. Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, et al. (2013) Platelet-Rich Plasma
Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow: A Double-Blind,
Prospective, Multicenter, Controlled Trial of 230 Patients. Am J Sports Med.
doi:10.1177/0363546513494359.
10. Wright-Carpenter T, Klein P, Schaferhoff P, Appell HJ, Mir LM, et al. (2004) Treatment of muscle
injuries by local administration of autologous conditioned serum: a pilot study on sportsmen with muscle
strains. Int J Sport Med 25: 588–593.
11. Hamilton BH, Best TM (2011) Platelet-enriched plasma and muscle strain injuries: challenges imposed by
the burden of proof. Clin J Sport Med 21: 31–36.
12. Andia I, Sanchez M, Maffulli N (2011) Platelet rich plasma therapies for sports muscle injuries: any
evidence behind clinical practice? Expert Opin Biol Ther 11: 509–518.
13. Sherrington C, Herbert RD, Maher CG, Moseley AM (2000) PEDro. A database of randomized trials and
systematic reviews in physiotherapy. Man Ther 5: 223–226.
14. Rettig AC, Meyer S, Bhadra AK (2013) Platelet-Rich Plasma in addition to rehabilitation for acute
hamstring injuries in NFL players clinical effects and time to return to play. Orthop J Sport
Med.doi:10.1177/2325967113494354.

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Ramadan and Sports Performance

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

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

Aerobic Performance
Studies have shown that during Ramadan, measured maximal oxygen intake have shown not to be
affected after 2 or 4 weeks of fasting (3) or in the performance of submaximal aerobic exercise (4). Similarly
estimated VO2max has been reported as being unchanged during Ramadan in competitive runners (5) and elite
Judokas (6). Running velocity and distance covered during shuttle running test also appears unaffected by
Ramadan fasting (7-9).
On the other side, studies have shown that Ramadan fasting has an effect on aerobic performance.
Sweileh et al. (10) noted some decreases in maximal oxygen intake during the first week of Ramadan. In an
other study, total distance and maximum aerobic velocity during Yo-Yo test was reduced by 12% and 14%
respectively in youth footballers (11) and time to complete a 3-km run was approximately 1% slower in
adolescent footballers (12). Aziz and colleagues (13) using a cross-over design before and during Ramadan
showed that the average distance covered during a 30 min time trial was reduced by ~4% during Ramadan
compared to before Ramadan. Similarly, Stannard & Thompson (14) found that 4 out of 8 subjects were unable
to complete the final 10min of a 30 min progressive cycle ergometer test during Ramadan. In footballers,
Zerguini et al. (15) noted that at the end of Ramadan there was a 16% decrease in the distance covered during a
12 min run conducted at 2pm with partial recovery in distance covered 2 weeks after Ramadan. In 5000m
running performance, Brisswalter et al (5) showed there was a 5% increase (slower) in 5000m times at the end of
Ramadan but there was no change in the maximal aerobic power or their running efficiency.
These results show that Ramadan related deterioration in maximal aerobic performance of less than 10
min duration is not observed but with longer bout of endurance exercise there is some deterioration as effort
continues. However, it remains unclear whether this decrease in performance is due to depletion of glycogen
(liver) reserves, progressive dehydration or simply due to subject’s poorer motivation or a combination of these
factors.

Anaerobic Power and Capacities

Ramadan fasting has shown to reduce anaerobic performance depending on the time the study is
conducted. In short distance sprints, a study showed that 100m and 800m performances were affected by fasting
(16). With regard to sprint times, Meckel et al. (12) showed a small 0.8% decrease in repeated 40m sprint and a
5.3% decrease in overall 40m sprint performance during Ramadan when conducted 13h after breakfast.
Kirkendall & colleagues (9) reported a 2% increase in 30m repeated sprint times in Ramadan fasting footballers
when conducted in the afternoon. Similarly Senegalese sprinters had a negative effect of fasting on 3 x 150m and
3 x 250m sprint performance (17). However, Tunisian Judokas could maintain their sprint speeds throughout
most of Ramadan but were approximately 4% slower over 3-m, 10-m and 30-m at the end of Ramadan (6).
With reference to power output measures, peak power, mean power and maximal power of Wingate
performance, appears to be essentially unaffected when tested in the morning during Ramadan (18, 19) but

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anaerobic power was reduced greatly in the afternoon and evening when compared with the non-fasting control
period (19, 20).
In terms of power output measure, maximum power test appear to essentially unaffected when tested in
the morning during Ramadan but anaerobic power were substantially reduced when tested in the afternoon and
evening.

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

References
1. Ziaee V, Razaei M, Ahmadinejad Z, Shaikh H, Yousefi R, Yarmohammadi L, Bozorgi F. Behjiati MJ. The
changes of metabolic profile and weight during Ramadan fasting. Singapore Med J. 2006;47:409-414.
2. Singh R, Hwa OC, Roy J, Jin CW, Ismail SM, Lan MF, Hiong LL, Aziz AR. Subjective perception of
sports performance, training, sleep and dietary patterns of Malaysian junior Muslim athletes during
Ramadan intermittent fasting. Asian J Sports Med. 2011;2:167-176.
3. Ramadan JM, Barac-Nieto M. Cardio-respiratory responses to moderately heavy aerobic exercise during
the Ramadan fasts. Saudi Med J. 2000;21:238-244.
4. Ramadan J, Telahoun G, Al-Zaid NS, Barac-Nieto M. responses to exercise, fluid and energy balances
during Ramadan in sedentary and active males. Nutrition 1999;15:735-739.
5. Brisswalter J, Bouhlel E, Falola JM, Abbiss CR, Vallier JM, Hausswirth C. Effects of Ramadan
intermittent fasting on middle-distance running performance in well-trained runners. Clin J Sport Med
2011;21:422-427.
6. Chaouachi A, Coutts AJ, Chamari K, Wong DP, Chaouachi M, Chtara M, Roky R, Amri M. Effect of
Ramadan intermittent fasting on aerobic and anaerobic performance and perception of fatigue in male elite
judo athletes. J Strength Cond Res 2009;23:2702-2709.
7. Aziz AR, Slater GJ, Chia MYH, The KC. Effects of Ramadan fasting on training induced adaptations to a
seven-week high-intensity interval exercise programme. Sci Sports 2012;27:31-38.
8. Guvence A. Effects if Ramadan fasting on body composition, aerobic performance and lactate, heart rate
and perceptual responses in young soccer players J Hum Kinetics 2011;29:79-91.
9. Kirkendall DT, Leper JB, Bartagi Z, Dvorak J, Zerguini Y. The influence of Ramadan on physical
performance measures in young Muslim footballers. J Sports Sci 2008; 26 (Suppl 3):S15-S27.
10. Sweileh N, Schnitzler A, Hunter GR, Davis B. Body composition and energy metabolism in resting and
exercising Muslims during Ramadan fast. J Sports Med Phys Fitness 1992;32:156-163.
11. Hamouda O, Chtourou H, Farjallah MA, Davenneb D, Souissi N. The effect of Ramadan fasting on the
diurnal variations in aerobic and anaerobic performance in Tunisian youth soccer players. Biol Rhythms
Res 2011;1:1-15.
12. Meckel Y, Ismael A, Eliakim A. The effect of the Ramadan fast on physical performance and dietary
habits in adolescent soccer players. Eur J Appl Physiol 2008;102:651-657.
13. Aziz AR, Wahid MF, Png W, Jesuvadian CV. Effects of Ramadan fasting on 60 min of endurance running
performance in moderately trained men Br J Sports Med 2010;44:516-521.
14. Stannard SR, Thompson MW. The effects of participation in Ramadan on substrate selection during
submaximal cycling exercise. J Sci Med Sports 2008;11:510-517.
15. Zerguini Y, Kirkkendall D, Junge A, Dvorak J. Impact of Ramadan on physical performance in
professional soccer players. Br J Sports Med 2007;41:398-400.
16. Ben Salama F, Hsairi M, Belaid J, Achour N achour A, Nacef T. Food intake and energy expenditure in
high school athletes before, during and after the month of Ramadan: effect of fasting on performance.
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17. Faye J, Fall A, Badji L, Cisse F, Stephan H, Tine P. Effects of Ramadan fast on weight, performance and
glycemia during training for resistance. Dakar Med 2005;50:146-151.
18. Abedelmalek s, Souissi N, Takayuki A, Hadouk S, Tabka Z. Effect of acute maximal exercise on
circulating levels of Interleukin-12 during Ramadan fasting. Asian J Sports Med 2011;2:154-160.

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19. Chtourou H, Hammouda O, Chaouachi A, Chamari K, Souissi N. The effect of time-of-day and Ramadan
fasting on anaerobic performance. Int J Sports Med 2012;33:142-147.
20. Souissi N, Souissi M, Souissi H, Chamari K, Tabka Z, Dogui M, Davenne D. Effect of time od day and
partial sleep deprivation on short-term, high-power output. Chronobiol Int 2008;25:1062-1076.

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Obesity, physical activity among subjects with

Intellectual Disabilities: Considerations to promote
of the level of Physical activity

Subasi F.1.

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

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

Obesity has been linked to a wide variety of health problems, including cancer, cardiovascular diseases,
and diabetes mellitus (1-5). The rapid rise in the prevalence of obesity and overweight are increasing across
Turkey (6-9) with the overall prevalence of obesity in adults being 18.6% in the year 1990. However, the
prevalence of obesity was found to be 25.3% for Turkish males and 44.2% for Turkish females in the year 2001
(10). According to large multicenter nationwide major studies TEKHARF study carried out in 1990 and 2000
(Turkish Adults and Risk Factors Study) and TURDEP study in 1999 (Turkish Diabetes Epidemiology Study)
looked at the prevelance of obesity, diabetetes and hypertension in Turkey. Despite differences in methodology
of the studies the results indicated that the prevelance of the obesity and overweight continues to increase in
our country as well as all over the world.
It was indicated in TEKHARF that BMI was used as an independent risk factor for CVD in men and
the cardiovascular risk were found to be increasing 9% in every 1 kg/m² BMI increment (11,12). Obesity
prevalence (BMI>29.9 kg/m²) was found to be 22% in TURDEP while in TEKHARF study it was found to be
21.1% among males and 43.0% in females (12). The results indicates also the importance of monitoring obesity
nationwide and in different regions of the Turkey, because there is a great difference in socioeconomic status
between the populations who live in different parts of the country. A study by Krassas (13) et al. investigated
the prevalence of overweight and obesity among children and adolescents in the city of Thessaloniki, Greece and
in the Kayseri area of Turkey. The results showed that the prevalence of overweight for Greek school children
was 22.2% while that of Turks was 10.6%. The obesity prevalence was 4.1% and 1.6%, respectively while the
total number of overweight and obese children were 26.3% and 12.2%, respectively (13). Childhood obesity is
very worrisome because %70 of obese teenagers will remain obese in adulthood ( 14,15)
The prevalence of obesity in the population with Intellectual Disabilities ( ID) has been shown to be
more common than in the general population (14-20). It was identified the rate of being obese ( BMI> 30.0
kg/ m²) and overweight ( BMI> 25.0 kg/ m²) as totally 20.7 % among individual with mild moderate ID ( n=
59, aged between 7-22 years, 13.83±2.44 years ) (16). In USA, overall, 15.6% of men and 25.1% of woman were
obese ( older age, and gender, living in institute or home, degree of ID, having other impairments effect that
ratio ( 17 ). In Europe, the prevelance of the obesity in children is 6.8%, and 3.5 % in France (15). The
increasing prevalence of being overweight in children and in adolescents with ID is associated with reduced
physical activity levels, having sedentary life style and lower fitness levels than general population (18,19)
Mobility problems appear to be 14 times more frequent in people with ID (20,21) The increasing prevalence of
over weight in children and adolescents with ID associate with reduced physical activity level (15, 22). Subasi et
al. showed that the prevalence of the sports habit in the children with ID was 31.1 % for both genders and the
vast majority of the children with mental disabilities were overweight or obese. It was also found that body mass
index was statistically negative associated with sit-up, standing broad jump test scores, 50- dash running time
among children with ID (16). Lack of opportunity for exercise, poor eating habits, too much passive
recreations, as well as using antipsychotic medications contribute to this problem (22, 23).
Sedentary life style are common place for those with ID and the fitness levels have been found to be
lower than for the general population (24,25). Also, various studies indicate that the high prevalence of obesity
in children and adults is a result of a life style that increases obesity prevalence with age (26,27). Sports and
Regular Physical Activity are meaningful and important in lives of many people, including those with ID.
Effectively including persons with ID in sport and PA not only requires in dept knowledge of their physical skill,

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physical fitness, social skill development, but also of their mutual retaltionship between cognitive and
neurophysiological potential of them (28)..However, there is serious concern that the individuals with ID may
not be receiving adequate levels of physical education (29). It was demonstrated also that the ratio of the
regular physical activity habits in the children with ID was 23.5 % for both genders (30). Thus, it may be
concluded that the barriers to participation in sports and PA among individuals with ID directly effects to PA
profile. It is also be recognized that people with ID have reduced access to range of health promotion program .
Access to health promotion and PA program has come under scrutiny (31). However, participation in sport and
physical activity is often a challenge for people, especially children, with ID because of poor motor functioning,
low motivation and difficulty in self monitoring. Therefore promoting physical activity level is likely to be
complex (23). They need simple field –based methods which can be performed easily in classrooms and
gymnasiums are solely for use by APA & APE (29). It may be suggested that successful application of
behaviour modification techniques in homes, classrooms, and institutional settings has stimulated interest in the
experimental analysis of procedures that might be used to teach parents, teachers, and others to apply those
techniques themselves. Therefore, the health promotion program can involve both parents and teachers that
includes encouraging and consulting them to promote leisure physical/sport activities for children with ID .
Determining factors associated with PA or inactivity may result in the development of effective
interventions for promoting regular physical activity. Although the major problem to participate physical
activity among subjects with ID, numerous theories and models can be used to promote a habit of regular
physical activity. However, the development of activity interventions or promotion programs is difficult because
no clear barriers/ facilitators have been identified through research (32,33).
In light of the literature; It can be concluded that inactive role models (teacher, family member),
competing demands and time pressures, unsafe environments, lack of adequate facilities, insufficient funds, and
inadequate access to quality daily physical education seem to be more prevalent among populations with special
needs (29,34) . Overall, environmental and family factors seem to be more significant determinants of
participation than characteristics of the children themselves (34 ) The long-term effects with regard to
maintaining participation in sport activity have not yet been evidenced. The number of the studies on
community based, well-designed and socially supported exercise-intervention programs seem to improve, but
the size of the sample must have larger population, as well.

References
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International Journal Obesity Related Metabolic Disorder, 1999. 23(3): p. 253-9.
2. Stouffer, K. and S.M. Dorman. Childhood obesity: a multifaceted etiology. International Electronic
Journal of Health Education, 1999. 2(2): p. 66-72.
3. da Veiga, G.V., P.C. Dias, and L.A. dos Anjos, A comparison of distribution curves of body mass index
from Brazil and the United States for assessing overweight and obesity in Brazilian adolescents. Revista
Panamericana de Salud Pública, 2001. 10(2): p. 79-85.
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436-44.
5. Aarnio, M., Leisure-Time Physical Activity In Late Adolescence: A Cohort Study Of Stability, Correlates
and Familial Aggregation In Twin Boys And Girls. Journal of Sports Science & Medicine, 2003. 2,
Supplementum 2: p. 1-41.
6. Yumuk, V.D., et al., High prevalence of obesity and diabetes mellitus in Konya, a central Anatolian city in
Turkey. Diabetes Reserach and Clinical Practice, 2005. 70(2): p. 151-8.
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8. Onat, A., et al., Sex difference in development of diabetes and cardiovascular disease on the way from
obesity and metabolic syndrome. Metabolism, 2005. 54(6): p. 800-8.
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10. Ersoy, C., et al., Comparison of the factors that influence obesity prevalence in three district
municipalities of the same city with different socioeconomical status: a survey analysis in an urban
Turkish population. Preventive Medicine, 2005. 40(2): p. 181-8.
11. Satman, I., et al., Population-based study of diabetes and risk characteristics in Turkey: results of the
turkish diabetes epidemiology study (TURDEP). Diabetes Care, 2002. 25(9): p. 1551-6.
12. Yalcin, B.M., E.M. Sahin, and E. Yalcin, Prevalence and epidemiological risk factors of obesity in
Turkey. Middle East Journal of Family Medicine, 2004. 6(6): p. 1-11.

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13. Krassas, G.E., et al., Prevalence of overweight and obesity among children and adolescents in
Thessaloniki-Greece and Kayseri-Turkey. Pediatric Endocrinology Reviews, 2004. 1 Suppl 3: p. 460-4.
14. Subasi, F., et al., Onset of smoking behaviors and participation in leisure physical activities of Turkish
adolescents attending vocational health schools International Electronic Journal of Health Education,
2006. 9: p. 81-91.
15. Salaun, L. and Berthouze-Aranda, S. Obesity in School Children with Intellectual Disabilities in France.
Journal of Applied Research in Intellectual Disabilities 2011. 24, 333–340.
16. Subasi, F., Luleci, E., Mumcu, G., Koksal, L., Inal, S., Hey, W. A Health Promotion Model for Turkish
Children with Mental Disabilities. 8. Annual Hawaii International Conference on Education. Honollu,
Hawaii, USA, January 7-10, 2010
17. Rimmer, J.H., Yamaki, K. Obesity and intellectual disability. Mental Retardation Developmental
Disabilities Research Review, 2006. 12(1):22-7.
18. Davis, K., Zhang, G. and Hodson, P. Promoting Health-Related Fitness for Elementary Students With
Intellectual Disabilities Through Specifically Designed Activity Program. Journal of Policy and Practice
in Intellectual Disabilities, 2011. 8 ( 2): 77–84.
19. Verel, S., F. Subasi, and T. Erbaydar. Factors Influencing body mass index among children and
adolescents with mental retardation. in Proceedings of the 7th International Congress of Sports Medicine
Association of Greece. 2004. Drama, Greece.
20. Hove, O., Weight survey on adult persons with mental retardation living in the community. Research in
Developmental Disabilities, 2004. 25(1): 9-17.
21. Krahn, G.L., Hammond, L. and Turner, A cascade of disparities: health and health care access for
people with intellectual disabilities. Mental Retardation and Developmental Disabilities Research
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22. Shea, S.E., Mental retardation in children ages 6 to 16. Seminars in Pediatric Neurology, 2006. 13(4): p.
262-70.
23. van Schrojenstein Lantman-de Valk, H.M.J., Health in People with Intellectual Disabilities: Current
Knowledge and Gaps in Knowledge. Journal of Applied Research in Intellectual Disabilities, 2005. 18(4):
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24. Todd, T. and Reid, G. Increasing Physical Activity in Individuals With Autism. Focus on Autism & Other
Developmental Disabilities, 2006. 21(3): p. 167-176.
25. Harris, N., et al., Prevalence of obesity in International Special Olympic athletes as determined by body
mass index. Journal of the American Dietetic Association, 2003. 103(2): p. 235-7.
26. Fernhall, B., Physical fitness and exercise training of individuals with mental retardation. Medicine &
Science in Sports & Exercise, 1993. 25(4): p. 442-50.
27. Calle, E.E., et al., Body-mass index and mortality in a prospective cohort of U.S. adults. The New England
Journal of Medicine, 1999. 341(15): p. 1097-105.
28. Van de Vliet, P., Rintala, K. and Fro jd, J. et al. Physical fitness profile of elite athletes with intellectual
disability. Scandinavian Journal Medicine Science & Sports, 2006.16: 417–425.
29. Davis, K., Zhang, G. and Hodson, P. Promoting Health-Related Fitness for Elementary Students With
Intellectual Disabilities Through a Specifically Designed Activity Program. Journal of Policy and Practice
in Intellectual Disabilities, 2011. 8 ( 2): 77–84.
30. Subasi , F., et al., The Promotion of Physical Activity for Children with Menta retardation in TURKEY.
Journal of the Brazilian Society Adapted Motor Activity, December 2007. 12(1): p. 170-174.
31. Thomas, G. R. & Kerr, M. P. Longitudinal Follow-up of Weight Change in the Context of a Community-
Based Health Promotion Programme for Adults with an Intellectual Disability Journal of Applied
Research in Intellectual Disabilities, 2011. 24 (4): 381–387
32. Stanish, H.I., Temple, V. A. and Frey, G. C. Health-promoting physical activity of adults with mental
retardation. Mental Retardation and Developmental Disabilities Research Reviews 2006. 12(1): p. 13-21.
33. Bollard, M., Health promotion and learning disability. Nursing Standard, 2002. 16(27): p. 47-53; quiz 54.
34. Hutzler, Y. & Korsensk, O. Motivational correlates of physical activity inpersons with an
intellectual disability: a systematic literature review. Journal of Intellectual Disability Research, 2010. 54
( 9) : 767–786.
35. Murphy, N. A. and Carbone, P. A. Promoting the Participation of Children With Disabilities in Sports,
Recreation and Physical Activities Pediatrics, 2008.121; 1057- 1061.

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What is Special about Special Olympics?

Opportunities for Sports and Fitness for People with
Intellectual Disability

Toh TH1,2, Mah LHK1,3

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

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

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

Special Olympics and the Impact

People with ID have been excluded from many aspects of society, and are less likely to be physically
active9. Eunice Kennedy Shriver (1921 - 2009) believed that if given continuing opportunities, with proper
instruction and encouragement, people with ID can realize their potential, develop physical fitness, demonstrate
courage, as well as experience joy and friendship; and she found SO in 196810. SO is today the world largest
sports organization for people with ID to actively engaging and competing in Olympic-type sport, and to
promote understanding, acceptance and inclusion10,11. SO athletes of all ability levels participate through a
process called “divisioning” and recognized for their performance, as the Athlete Oath says “Let me win. But if I
cannot win, let me be brave in the attempt”10,11.
In 2011, the 4-yearly World Summer Games in Athens attracted more than 6,000 athletes, with an
additional 4 million participating in some 53,000 competitions in 170 countries11. In early 2013, more than 3,000
SO athletes from 111 countries took part in Pyeong Chang World Winter Games in South Korea10. Through
millions of these individual and worldwide acts of inclusion where people with and without intellectual
disabilities are brought together, SO believes long-standing myths are dispelled, negative attitudes changed and
new opportunities to embrace and celebrate people with ID are created. In addition, in response to call for

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

Special Olympics Healthy Athletes Program

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

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Health Data from the HAP

Heath data generated from the SO HAP at the United States in 2001 has supported the belief that SO
athletes have relatively poorer health status such as substantial levels of untreated caries and oral pain and related
to poor oral hygiene16. At the same time, comparing to the American athletes, the international athletes from
China, Lebanon, Poland, South Africa, and Turkey were more likely to have untreated caries (50.1 versus
28.2%), and less likely to have restorations (19.6 versus 62.9%), sealants (1.8 versus 13.5%), fluorosis (3.5
versus 8.8%), signs of gingival disease (27.8 versus 40.1%), or to be edentulous (0.1 versus 3.7%) 17.
Table 2 shows some of the HAP results compiled from the seven SO world regions between 2007 and
2011. While there are athletes from certain regions who have higher rates of certain problems, the phenomenon
is worldwide. More than 20% of SO athletes have untreated tooth decay and gingival signs in addition to 6 –
24% requiring urgent dental referral for severe pain, abscess and deep caries. In Fit Feet®, 10 – 30% of the SO
athletes have bone deformation (e.g. hammertoes, brachymetarsia and bunions) and more than half have skin or
nail conditions that required medical attention (e.g. infection, ingrown nails, ulcers, dry skin). On average about
15% of the athletes have eye diseases (e.g. blepharitis and amblyopia) and 30% of them needed glasses or new
glasses; while nearly 20 – 35% has hearing problems. On average, more than 22% of the athletes worldwide
have low bone density and nearly 40% of them were overweight or obese. There were also significant numbers
of athletes who have flexibility and balance problems. These findings are discouraging, given that these athletes
represented a generally better-supported and higher-functioning stratum of people with ID worldwide.
Table 3 shows data from Malaysian athletes registered with SO to-date. Comparing with the SO athletes
in Asia Pacific region, Malaysian athletes seemed to be faring better with lower prevalence of eye disease,
needing new glasses, pure tone hearing loss, flexibility and balance problems. During the Sarawak State Games
in 2010, 31.5% (children) and 36.9% (adult) of the 138 athletes screened were considered overweight or obese,
and more than 20.0% of the adult athletes were hypertensive or at risk of hypertension18. While there are many
consistency and similarities, health data available can allow the local professional to address the specific issues
faced by the SO athletes in Malaysia.

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Other Special Olympics Initiatives

Besides sports and HAP, some of the other initiatives aiming at providing a more holistic program for
the SO athletes and their families are10,11:
 Healthy Communities that aims to achieve improved health outcomes by ensuring health
services and reaching full potential for people with ID. It addresses some acute medical problems (e.g. malaria,
tuberculosis, waterborne diseases), and conditions more prevalent in developed countries (e.g. obesity, early
onset of chronic diseases).
 Family Health Forum that provides families and community or professionals to interact and
learn from each other regarding the needs of SO athletes in healthcare, education and inclusive activities.
 Family Support Network which offers families a support system within SO.
 Special Olympics Young Athletes™ provides opportunity for young children with ID (2 to 7
years old) in sports training.
 Special Olympics Unified SportsTM brings together people with and without ID on the same
athletic team.
 Special Olympics Athlete Leadership Programs (ALPs) that offer athletes the opportunity
to take active leadership roles both on and off the playing field; and serving on the Boards of Directors, officiate
competitions, coach other athletes and make decisions about the future of SO.

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

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

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13. Adnams CM. Perspectives of intellectual disability in South Africa: epidemiology, policy, services for
children and adults. Curr Opin Psychiatry; 23(5):436-40, 2010 Sep.
14. Lin LP, Lin JD. Perspectives on intellectual disability in Taiwan: epidemiology, policy and services for
children and adults. Curr Opin Psychiatry; 24(5):413-8, 2011 Sep.
15. Morin D, Merineau-Cote J, Ouellette-Kuntz H, Tasse MJ, Kerr M. A comparison of the prevalence of
chronic disease among people with and without intellectual disability. Am J Intellect Dev Disabil;
117(6):455-63, 2012 Nov.
16. Reid BC, Chenette R, Macek MD. Special Olympics: the oral health status of U.S. Athletes compared with
international athletes. Special Care in Dentistry; 23(6):230-3, 2003 Nov-Dec.
17. Reid BC, Chenette R, Macek MD. Prevalence and predictors of untreated caries and oral pain among
Special Olympic athletes. Special Care in Dentistry; 23(4):139-42, 2003 Jul-Aug.
18. Toh TH, Nurhilda A, Chua SY, Muhamad Rais A, Islia N, et al. Body mass index, blood pressure, visual
acuity and hearing status of Special Olympics Athletes in Sarawak. Int J Public Health Res (special issue):
66-71, 2011.

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

healthy young men

Maeda N.1, Urabe Y.1, Fujii E.1, Shinohara H.1, Sasadai J.1, Moriyama N.1, Kotoshiba S.1,
Yamamoto T.1
1
Hiroshima University, (Japan)
e-mail:[email protected]

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

Introduction
The risk of musculoskeletal injury is a concern in physical training. Predisposing factors for injury
include age, gender, injury history, body size, local anatomy and biomechanics, aerobic fitness, muscle strength,
imbalance, tightness, ligamentous laxity, central motor control, psychological and psychosocial factors, as well
as general mental ability[1] [2]. To prevent traumatic injuries, it is necessary not only to understand their
etiology and underlying mechanisms but also to develop means for early detection of the above-mentioned
predisposing factors.
However, in many medical centers, screening of athletes and non-athletes is still based on personal
experience, subjective observations, and mental evaluations. In fact, initially, few standardized assessment
devices and evaluation indexes for posture and movement patterns existed. More recently, screening has shifted
towards a more functional approach based on the assumption that identifiable biomechanical deficits in
fundamental movement patterns have the potential to limit performance and render the athlete susceptible to
injury[3]. This type of screening requires the rater to have experience in observation and good knowledge of
functional anatomy and kinematics.
Recently, Cook et al. [4] [5] have developed the Functional Movement ScreenTM ( FMSTM ) of a tool to
assess fundamental movement skills. The tool consists of 7 functional movements that assess flexibility,
neuromuscular coordination, trunk and core strength and stability, asymmetry in movement, acceleration,
deceleration, and dynamic flexibility [6].
The FMSTM system has been validated, however its intrarater and interrater reliability between groups
of physical therapists with varying amounts of experience to determine if clinical experience and previous
experience using the FMSTM has not been reported [4] [5]. Therefore, this study aimed to examine intrarater test–
retest and interrater reliability of FMSTM demonstrated among physical therapists for healthy volunteer men
students.

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Material and Methods

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

1.2. Methods
The rater participating in this study consisted of 2 physical therapists with more than 4 years’
experience. The primary rater for the intersession reliability was a credentialed performance specialist with
FMSTM Certified expert. Novice individuals were defined as having taken the standardized introductory training
by an expert and have used the FMSTM more than a year. The secondary rater read the FMSTM manual before
scoring the FMSTM and had scored the FMSTM during some type of testing trial for healthy person and athletes.
Two physical therapists were randomly assigned to the participants to assess intrarater test-retest reliability by
assessing the FMSTM on day 1 and day 2. The subjects arrived at the University’s Sports Rehabilitation Research
Laboratory wearing athletic clothing. The subjects were tested on 2 days, separated by 1 week. On both days, the
subjects performed the FMSTM test. One week later, the subjects retested to the Sports Laboratory, and each
subject performed the same assessments in the same order.
The FMSTM is designed so that the 7 fundamental movement patterns are considered together as a
comprehensive cross section of functional movement. These 7 tests, used to assess overall functional movement
ability, include the deep squat (DS), the hurdle step (HS), the in-line lunge (IL), the shoulder mobility (SM), the
active straight leg raise (ASLR), the trunk stability push-up (TSP), and the rotary stability (RS) (Cook et al.,
2006a; 2006b). There are 3 clearing tests, each associated with one of the individual FMSTM tests, which check
for pain accompanying shoulder internal rotation/flexion and end-range spinal flexion and extension pain. The
FMSTM is scored on a 0-3 ordinal scale. A score of 3 represents the subject’s ability to perform the functional
movement pattern as described, a score of 2 indicates that some type of compensation is present when
completing the pattern, and a score of 1 is given when the subject is unable to perform the movement pattern. A
zero is recorded if there is pain associated with any portion of the test including the clearing tests. The lowest
score from the three trials was used for scoring. From 7 movements, a composite score was calculated out of a
potential 21 points, with higher scores indicating the greatest function.
The difference in mean values between the total FMSTM score measured by rater 1 was used the paired
t-test [4] [5]. Test-retest reliability for the FMSTM item scores and total score was determined by using an
ICC1,1. The ICC1,1 was used to determine the reliability of the intersession scoring of the FMSTM and the
intrasession interrater scoring of the FMSTM. The researchers interpreted the ICC reliability according to the
following criteria: high reliability, 0.90–0.99; good reliability, 0.80–0.89; fair reliability, 0.70–0.79; poor
reliability, 0.00–0.69 [7]. Intersession reliability and interrater reliability for the FMSTM item scores (DS, HS, IL,
SM, ASLR, TSP, and RS) was determined by using a weighted Cohen’s kappa (kappa) used for categorical data.
The interpretations of the weighted kappa were based on Landis and Koch[8]: Excellent reliability, 0.81–1.0;
good reliability, 0.61–0.80; moderate reliability, 0.41–60; fair reliability, 0.21–0.40; poor reliability, <0.20.

1.2. Statistical analysis

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

Results
For the intrarater reliability of Rater 1, the ICC (95%CI) was 0.95 (0.94-0.97) for the FMSTM i total
score. The mean for total FMSTM score of 1 day for subjects was 16.6 ± 1.6 and for the score of 2 day was 16.6 ±
1.6. The difference in mean values between the total FMSTM score was no significant (Table 1).
The tests were analyzed by addressing the kappa values of both individual right and left sides for each
of the 7 tests. The inter-rater reliability (kappa) for each score of the individuals’ right and left side performance
and for the final score for each test is presented in Table 2.

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TM
Tab 1. Intra-ratar reliability in overall FMS

TM
FMS Minimum Maximum 95%CI ICC1.1
TM
1day FMS 16.5 ± 1.5 14 19
TM
0.94-0.97 0.95
2day FMS 16.6 ± 1.5 14 19
Mean±Standard Diviation，ICC = Intraclass crrelation coefficient

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

TM
FMS items Agreement (%) Kappa Agreement Level
Deep Squat 90 0.61 good

Hurdle Step (Rt) 90 0.79 good

Hurdle Step (Lt) 100 1.00 excellent

In-line Lunge (Rt) 80 0.55 moderate

In-line Lunge (Lt) 100 1.00 excellent

Shoulder Mobility (Rt) 90 0.61 good

Shoulder Mobility (Lt) 100 1.00 excellent

Active Straight Leg raise (Rt) 100 1.00 excellent

Active Straight Leg raise (Lt) 90 0.83 excellent

Trunk Stability push up 90 0.63 good

Rotary Stability (Rt) 100 1.00 excellent

Rotary Stability (Lt) 80 0.63 moderate

The pair of raters demonstrated excellent agreement on 6 of the 12 test components, including HS (Lt),
SM (Lt), ASLR (Both), and RS (Rt). Good agreement was evident on 4 of the 12 test components including DS,
HS (Rt), SM (Rt), and TSP. IL (Rt) and RS (Lt) demonstrated moderate agreement. The remaining scores
demonstrated good agreement between two raters.

Discussions
Fundamental movements, such as those tested in FMSTM, operate as the basis of more complex
movement patterns used in common daily activities and sports. The results of our interrater reliability for FMSTM
total score are similar with those previously reported by Onate et al. [9]. The mean composite score reported in
this study is slightly lower than that reported for a group of professional male football players (16.9 points) [10].
It might be expected that professional football players score better than the average athlete due to their intensive
training regimens.
In this study, we showed that FMSTM is a fundamental movement-screening tool with moderate-to-high
intersession reliability and good-to-high interrater reliability for healthy young men. Hence, physical therapists
and other health professionals may use FMSTM as a training system for preventing injuries and improving
physical performance of athletes and non-athletes. For intrarater reliability of Raters 1, ICC was 0.95, indicating
high reliability in all cases. In previous studies, Currier [11] stated that 0.90–0.99 = high reliability, 0.80–0.89 =
good reliability, 0.70–0.79 = fair reliability, and <0.69 = bad reliability. Chinn [12] reported that a device was
useful if the ICC was > 0.6. Based on these studies, this study can suggest that the FMSTM is reliable and useful
for applications. The results supported hypothesis of this study. A preliminary study by Minick et al. [13] found
acceptable levels of interrater agreement on FMSTM component scores among novice and expert raters in a
sample of active college-age participants using videotape review. However, in this study, interrater agreement
was only calculated for individual FMSTM component scores and not for the overall FMSTM composite score;
moreover, test–retest reliability was not assessed. In another study, Gribble et al. [14] reported that FMSTM
demonstrated moderate-to-strong intrarater reliability among clinicians but not among students preparing to be
athletic trainers. It appears that an experienced physical therapist can contribute to the reliability of FMSTM
across testing sessions. However, Teyhen et al. [15] reported moderate-to-good interrater and intrarater

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reliability among novice raters too. Therefore, experience in observation may not be the only factor influencing
interrater and intersession reliability.
The FMSTM can be performed with good intersession and interrater reliability for each task of the
system, with caution warranted for IL and RS component. In our study, IL and RS task yielded the lowest kappa
value for intrasession interrater reliability. Minick et al. [13] reported that DS and IL yielded substantial to
moderate reliability in both intersession and interrater reliability assessments. Similary, Schneiders et al. [3]
reported that IL yielded substantial reliability in interrater reliability assessments. A possible explanation for this
low reliability is that IL and RS are dynamic movements, with both hip and knee joints being simultaneously
assessed in a closed kinetic chain [10]. Furthermore, the rater’s observation location could have played a key role
in the poor interrater reliability of IL and RS. Onate et al. [9] indicatede the real-time assessment of the
simultaneous 3-dimensional assessment of hip flexion and external rotation, the raters positioning when
assessing this test is quite important. A limitation of this study was the relatively small sample size and the
inclusion of young men participants alone. Therefore, generalization of our findings to the general population is
not possible without further investigation. However, despite these limitations, the FMSTM remains a reliable
measurement tool for functional movement analysis.
In conclusion, FMSTM is a highly reliable test battery for functional movement analysis demonstrated
among physical therapists in healthy young men. Further studies are necessary to measure the reliability of
FMSTM scores in women and athletes. Future studies need to be performed using clinical outcomes to confirm
the effectiveness of the screening tool a function to predict the risk of personal injury physically active
individuals.

References
[1] Taimela S, Kujala UM, Osterman K. (1990). Intrinsic risk factors and athletic injuries. Sports Med 9(4),
pp. 205-215.
[2] Devan MR, Pescatello LS, Faghri P, Anderson J. (2004). A prospective study of overuse knee injuries
among female athletes with muscle imbalances and structural abnormalities. J Athletic Training 39(3), pp.
263-267.
[3] Schneiders AG, Davidsson A, Hörman E, Sullivan SJ. (2011). Functional movement screen normative
values in a young, active population. Int J Sports Phys Ther 6(2), pp. 75-82.
[4] Cook G, Burton L, Hoogenboom B. (2006). Pre-participation screening: The use of fundamental
movements as an assessment of function - Part 1. N Am J Sports Phys Ther 1(2), pp. 62-72.
[5] Cook G, Burton L, Hoogenboom B. (2006). Pre-participation screening: The use of fundamental
movements as an assessment of function - Part 2. N Am J Sports Phys Ther 1(3), pp.132-139.
[6] Pollock ML, Gaesser GA, Butcher JD, Despres JP, Dishman RK, Franklin BA, Garber CE. (1998). The
recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and
muscular fitness and flexibility in health adults. Medicine and Science in Sports and Exercise 30(6), pp.
975-991.
[7] McGuine TA, Greene JJ, Best T, Leverson G. (2000). Balance as a predictor of ankle injuries in high
school basketball players. Clin J Sport Med 10(4), pp. 239–244.
[8] Landis JR, Koch GG. (1977). The measurement of observer agreement for categorical data. Biomechanics
33(1), pp. 159–174.
[9] Onate JA, Dewey T, Kollock RO, ThomasKS, Van Lunen BL, DeMaio M, Rinqleb SI. (2012). Real-time
intersession and interrater reliability of the functional movement screen. J Strength Cond Res 26(2), pp.
408-415.
[10] Kiesel K, Plisky PJ, Voight ML. (2007). Can serious injury in professional football be predicted by a
Preseason Functional Movement Screen? N Am J Sports Phys Ther 2(3), pp.147-158.
[11] Currier DP. (1990). Elements of research in physical therapy. Third ed. Baltimore: Williams and Wilkins,
pp. 167.
[12] Chinn S. (1991). Repeatability and method comparison.Thorax 46(1), pp. 454–456.
[13] Minick KI, Kiesel KB, Burton L, Taylor A, Plisky P, Butler RJ. (2010). Interrater reliability of the
functional movement screen. J Strength Cond Res 24(1), pp. 479-486.
[14] Gribble P, Brigle J, Pietrosimone B, Pfile KR, Webster KA. (2010). Intrarater reliability of the Functional
Movement ScreenTM. J Strength Cond Res 24(2), pp. 479-486.
[15] Teyhen DS, Shaffer SW, Lorenson CL, Halfpap JP, Donofry DF, Walker MJ, Dugan JL, Childs JD.
(2012). The Functional Movement Screen: a reliability study. J Orthop Sports Phys Ther 42(6), pp. 530-
540.

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The Effects of Changes in Rules and Regulations on

Sepaktakraw Match Performance

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

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

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

Introduction
Sepaktakraw, whose origin is said to date back to the 9th century, is a popular sport in Southeast Asia.
Official rules and regulations have been developed internationally in recent decades. Competitive players are
required complex ball skills (kicking and juggling), agility, and the ability to perform acrobatic movements on a
court similar in size to that of a badminton court during a match. The team consists of three players and is
performed like volleyball, except that use of hands and arms is not permitted. A competitive sepaktakraw game
is characterized by the integration of five skills: serving, reception, setting, attacking, and blocking.
Sports sciences have contributed greatly to the development of modern sports such as soccer, tennis,
volleyball, etc. Breakthroughs in computer technology in recent years have contributed to advancing
dramatically notational match analysis. However, sepaktakraw lacks worldwide popularity; therefore, scientific
evidence regarding this sport has been limited (Aziz et al., 2003, Jawis et al., 2005, Joseph et al., 2009,
Nagahama, 2011, Sujae and Koh, 2008).
The International Sepaktakraw Federation (ISTAF), established in 1992, has implemented changes in
rules and regulations several times in the past. In 2011, ISTAF amended the rules and regulations and official
tournaments authorized by ISTAF have been operated on the basis of the new rules. The main changes were the
scoring system stipulation that each set is won by the side which scores from 21 to 15 points and the serving
system stipulation that service alternates every three points regardless of which side wins a point. The aim of
this study was to investigate the effects of changes in rules and regulations on match performance in
sepaktakraw. We hypothesized that serving events may affect the outcome of a match more than ever due to rule
changes.

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Method

Data Source, Collection, and Analysis

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

Notational Analysis
A notational analysis system was developed to modify the 2008 volleyball statisticians’ manual created
by the National Collegiate Athletics Association (NCAA, 2008). Serving and reception were selected from
among the specific skills because these would be affected by the new rules and regulations. Each of the skills’
definitions and assessment criteria are listed below:
Serve--- A serve is when a player attempts to kick the ball over the net into the opponent’s court. There
are four possible outcomes for every served ball:
(1) A service ace (SA) is a serve that results directly in a point. A SA is awarded (a) if the serve strikes
the opponent’s court untouched; (b) if the serve is passed by the opponent but cannot be kept in play; or (c) if the
referee calls a fault on the receiver (e.g., ball contact with hands or arms).
(2) A service error (SE) is charged (a) if the serve fails to go over the net and lands on the side of the
team serving; (b) if the serve is out of bounds; or (c) if the server foot-faults.
(3) A service effectiveness (SEF) is awarded if the serve is received by the opponent but this act creates
an unfavorable situation (e.g. the ball cannot be raised easily by a setter).
(4) A zero serve (ZS) occurs when a serve does not result in a SA, SE, or SEF, but play continues.
The success and failure rates of serves are expressed as follows:
total SA  total SEF total SE
success rate  failure rate 
total attempts total attempts
Reception--- A reception is when a player attempts to pass a served ball to a teammate. There are two
possible outcomes when a player attempts to pass a served ball:
(1) A reception success (RS) is awarded if the player continues play by successfully passing a served
ball.
(2) A reception error (RE) is charged (a) if the serve strikes the floor; (b) if the player passes the ball but
it cannot be kept in play; or (c) if the referee calls a fault (e.g., ball contact with hands or arms).
The success and failure rates of reception are expressed as follows:
total RS total RE
success rate  failure rate 
total attempts total attempts

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

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

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

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

Old rules New rules

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

Recovery duration (s): 28.2 ± 9.1 (9.1 - 75.0) 28.6 ± 7.9 (5.9 - 85.6)
***
Regular set duration (min : s): 19:31 ± 4:23 (12:58 - 28:06) 13:36 ± 2:42 (9:07 - 18:10)

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

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

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

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

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serving and reception) during the match with the change in rules and regulations revised in 2011. Our findings
demonstrated that the change in rules did not affect the duration of a rally or recovery; however, the duration of a
set was significantly shortened, suggesting that the progression of the match is faster (Tab.1). Sepaktakraw
players are not required to have high aerobic capacity (Asiz et al., 2003) and the duration of a rally is
approximately 5 s during a match (Asiz et al., 2003, Nagahama, 2011). For the more explosive actions (i.e.
serving, attacking, blocking, etc.) that appear frequently in a match, shorter duration of a set may reduce
physiological stress. On the other hand, the number of points required to win one set was changed from 21 to 15
points, increasing the importance of a single point in a game. The server performs aggressively to score first
from the beginning of a match; however, a service error directly advances the score in the opposing team.
Therefore, the server may suffer greater psychological stress than ever during a match. In this regard, we must
clarify the interviews with servers in the future.
Our findings also demonstrated that due to rule changes, the skill of the server would affect the outcome
of a match more than ever. The rule change to continue the serve three times continuously suggested the
possibility that the winning team could proceed with an advantage. On the other hand, in order to from a
disadvantaged position, the losing team must serve more aggressively to obtain a service ace or a reception error;
these tactics would cause a significant increase in the failure rate of serves for the losing team. Furthermore, it is
necessary not only to increase service aces and serve effectiveness and to decrease services errors, but also to
decrease zero serves that could be attacked easily by the opposition (Fig.1). Because continuous rallies are
limited in a match, if a reception succeeds, the score tends to be determined by the next play, in many cases an
attack (Nagahama, 2011). Serving and reception are closely linked; therefore, an exact serve with a change in
speed would induce a reception error. On the other hand, if the ability to receive could be enhanced, an attack
after a reception increases the probability of gaining the point (Nagahama, 2011). As a result, it would be
possible to proceed with an advantage in this situation. In particular, due to rule changes, reception performance
decreased only for losing teams (Fig. 1). These results suggest that to strengthen the ability of a reception is
urgently needed.
Notational analysis has been one of the effective methods for analyzing sports. This method is
especially utilized in competitions classified as net sports, such as volleyball (Han and Robert, 1992, Patsiaouras
et al., 2011), tennis (O’Donoghue and Ingram, 2001), and table tennis (Malagoli et al., 2013). The papers cited
here presented characteristics of these sports such as temporal data, playing style, rates of success and failure,
etc.; however, this information has been limited in the sepaktakraw research (Aziz et al., 2003, Nagahama 2011).
This study to analyze the rates of success and failure of specific skills represents the first notational analysis of
sepaktakraw competition (Fig.2); therefore, it will contribute to clarifying the scientific characteristics of
sepaktakraw.
In summary, our findings expand on the limited data in the previous literature regarding sepaktakraw.
We are able to demonstrate that new notational analysis can be utilized on research in this sport. The obtained
information will provide both coaches and players practical ideas for winning strategy.

References
[1] Aziz, AR., Teo, E., Tan, B., and Chuan, TK. (2003). Sepaktakraw: A descriptive analysis of heart rate
and blood lactate response and physiological profiles of elite players. International Journal of Sports
Science 15, 1-10.
[2] Han, JE., and Robert, WS. (1992). Statistical analyses of volleyball team performance. Research
Quarterly for Exercise and Sport 63, 11-18.
[3] Jawis, MN., Singh, R., Singh, HJ., and Yassin, MN. (2005). Anthropometric and physiological profiles of
sepaktakraw players. British Journal of Sports Medicine 39, 825-29.
[4] Malagoli, LI., Di, MR., and Merni, F. (2013). A notational analysis of shot characteristics in top-level
table tennis players. European Journal of Sports Science, http://dx.doi.org/10.1080/17461391.2013.
819382
[5] Nagahama, H. (2011). Scientific analysis in sepaktakraw. Journal of the society for general academic and
cultural research 18, 109-27. (In Japanese with English abstract)
[6] National Collegiate Athletic Association (NCAA). (2008). Volleyball statisticians’ manual.
[7] O' Donoghue, P., and Ingram, B. (2001). A notational analysis of elite tennis strategy. Journal of Sports
Sciences.19, 107-15.
[8] Patsiaouras, A., Moustakidis, A., Charitonidis, K., and Kokaridas, D. (2011). Technical skills leading in
winning or losing volleyball matches during Beijing Olympic Games. Journal of Physical Education and
Sport 11, 149-152.
[9] Sujae, IH., and Koh, M. (2008). Technique analysis of the kuda and sila serves in sepaktakraw. Sports
Biomechanics 7, 72-87.

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Resitance exercise with blood flow restriction in

women

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

Department of Sport Education, Hokusho University

Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine

Research Fellow of the Japan Society for the Promotion of Science

Hokkaido University of Education, Iwamizawa

Summary

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

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

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

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

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

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

Introduction

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

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

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

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

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

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

gender difference in muscular characteristics. Previously, we demonstrated that training effects such as strength
gain and muscle hypertrophy closely related to intramuscular metabolic stress during exercise9. Therefore, we

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

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Materials and Methods

Twenty-six age-matched men (n=13, 224 yrs) and women (n=13, 214 yrs) were recruited and
performed unilateral plantar-flexion (30 repetitions/min for 2 min). The exercise protocols were as follows:

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

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

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

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

(details in the previous studies6-9).

Results

Phosphocreatine decreases were statistically similar between men and women in all protocols (Fig 1).
Intramuscular pH decreases showed similar trend. Compared with L, metabolic stresses were enhanced similarly

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

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

Conclusions

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

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

greater.

Acknowledgements

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

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

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

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References

1) Braith RW, Stewart KJ. Resistance exercise training: its role in the prevention of cardiovascular disease.
Circulation, 2006;113:2642-50.

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

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

2004;6:101-7.

3) Kraemer WJ, Ratamess NA. Fundamentals of resistance training: progression and exercise prescription.
Med Sci Sports Exerc, 2004;36:674-88.

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

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

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

of twice daily KAATSU resistance training. Int J KAATSU Training Res. 2008;1:6-12.
6) Okita K. Effects of Blood Flow Restriction on Intramuscular Energetic Metabolism During Resistance
Exercise. Adv. Exerc. Sports Physiol. 2010;15:121-25.
7) Suga T, Okita K, Morita N, Yokota T, Hirabayashi K, Horiuchi M, Takada S, Takahashi T, Omokawa M,

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

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

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

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

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

2012;113:199-205.

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

K, Yokota T, Kinugawa S, Tsutsui H. Blood Flow Restriction Exercise in Sprinters and Endurance
Runners. Med Sci Sports Exerc. 2012;44:413-9.

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Ultrasonographic measurement of the posterior ankle region

at various plantar flexion angles

Sasadai J.1, Urabe Y.1, Maeda N.1, Fujii E.1, Shinohara H.1
1
Graduate School of Biomedical and Health Sciences, Hiroshima University (Japan)
e-mail:[email protected]

Abstract
Posterior ankle impingement syndrome (PAIS), a common disorder in soccer players and ballet dancers,
is characterized by posterior ankle pain with excessive plantar flexion. Soft tissue, bony processes, unfused
ossicles, or osseous fragments trapped between the posterior tibial plafond and superior calcaneus lead to
symptoms. However, whether such impingement occurs at higher than normal plantar flexion angles, as occurs
in soccer kicks and the pointe position in ballet, is not known. This study aimed to determine, from
ultrasonographic measurements, whether the distance between the tibia and calcaneus decreases as ankle plantar
flexion angle increases. Such knowledge could help explain the mechanism by which excessive ankle plantar
flexion causes PAIS.
Sixteen healthy volunteers (8 men, 8 women) with no history of foot or ankle injury consented to
participate. Posterior ankle images were captured using an LOGIQ e Expert ultrasound device at 7 dorsal/planter
flexion angles determined by a goniometer. Distance between the posterior tibial plafond and superior calcaneus
was measured on the sagittal plane using the inbuilt ultrasound analysis software. One-way ANOVA was used to
compare the distance in the 7 angle conditions. When interactions were detected, further analysis was carried out
using Scheffe’s test. P<0.05 was considered significant. All data analysis was performed using Statcel 2.
Distance between the posterior tibial plafond and superior calcaneus decreased as ankle plantar flexion
angle increased (men: 53.4±4.4 to 22.8±2.7 mm, women: 50.6±2.4 to 22.5±2.5 mm). Significant shortening was
apparent between maximal dorsal flexion and 30° plantar flexion (p<0.05), but not at 45° plantar flexion or
maximal plantar flexion. The distance may not have shortened further after 30° plantar flexion because certain
contact or impingement could have already occurred in the ankle posterior region.
Keywords: posterior ankle impingement syndrome, ultrasonography, ankle plantar flexion

Introduction
Posterior ankle impingement syndrome (PAIS), such as os trigonum syndrome, is a common sports
injury in soccer players and ballet dancers [1] [2]. PAIS is characterized by posterior ankle pain with forceful
ankle plantar flexion. Soft tissues, bony processes, unfused ossicles, or osseous fragments entrapped between the
posterior tibial plafond and the superior calcaneus lead to symptoms [1] [3].
However, our recent study showed that the angle of maximal ankle plantar flexion on ball impact does
not exceed that of passive maximal plantar flexion [4]. In addition, whether such impingement occurs at higher
than normal plantar flexion angles, as occurs in soccer kicks and the pointe position in ballet, is not known.
Ultrasonography is often used in the diagnosis of the musculoskeletal disease as quick, cheap and
widespread way [5]. Some studies had ultrasonographically observed sign of PAIS, such as thickening of the
joint capsule and triangular bone in posterior ankle region [3] [6]. However, to our knowledge, there have been
no published studies up to date that have observed change in the position relationship between tibia and
calcaneus.
The purpose of this study was to determine, from ultrasonographic measurements, whether the distance
between the tibia and calcaneus decreases as ankle plantar flexion angle increases. Such knowledge could help
explain the mechanism by which excessive ankle plantar flexion causes PAIS. We hypothesised if the ankle
plantar flexion angle increases, the distance between the tibia and calcaneus is shorten.

Material and Methods

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

1.2. Methods
The participants were seated on a chair. A transparent glass water tank (600*300*360 mm, EJ-60,
EHEIM, Japan) was used in order to capture clear ultrasonographic image, because it was difficult to capture
complex posterior ankle region in a common method using echo gel. The tank was filled with water. Water
temperature was controlled at 35°C, which is insensitive temperature. During the measurement, participants were
instructed to put their leg into the water tank without loading a lot. Both legs were measured. The sequencing of
right and left was randomized.
In the water tank, total of seven condition of ankle dorsal/planter flexion angle (maximal dorsiflexion,
15° dorsiflexion, 0° dorsiflexion/plantar flexion, 15° plantar flexion, 30° plantar flexion, 45° plantar flexion, and
maximal plantar flexion) were formed by using goniometer (Fig. 1). On each condition, posterior ankle images
were captured using ultrasonography (LOGIQ e Expert, GE Healthcare, Japan) in water (Fig. 2. A). One
examiner positioned the transducer and optimized the quality of the image, and the same examiner captured and
save the image. The probe position and gain of the ultrasonography system were fine-adjusted to display the
outlines of tibia and calcaneus on the monitor.
After all measurement were finished, imaging analysis was held using the inbuilt ultrasound analysis
software. Distance between the edge of the posterior tibial plafond and the superior calcaneus was measured on
the sagittal plane using the inbuilt ultrasound analysis software (Fig. 2. B).

1.3. Statistical analysis

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

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

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A B
Fig. 2. A: Scanning image in water bath.
B: Ultrasonographic image of posterior ankle region (Ti: Tibia, Ta: Talus, C: Calcaneus).

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

Tab. 1. Distance between the tibia and calcaneus.

Max DF 15° DF 0° DF/PF 15° PF 30° PF 45° PF Max PF
Men 53.4±4.4 47.5±4.3* 41.2±3.9*,† 33.0±3.9*,†,‡ 27.2±3.3*,†,‡,§ 24.0±3.1*,†,‡,§ 22.8±2.7*,†,‡,§
Women 50.6±2.4 46.6±2.9* 41.0±3.5*,† 34.5±4.2*,†,‡ 28.1±2.8*,†,‡,§ 24.4±2.9*,†,‡,§ 22.5±2.5*,†,‡,§
DF: dorsiflexion, PF: plantar flexion, Mean ± Standard Deviation
*: statistical difference between Max DF, †: statistical difference between 15° DF
‡: statistical difference between 0° DF/PF, §: statistical difference between 15° PF

Discussions
PAIS is recognized as chronic pain in athletes, such as soccer players and ballet dancers [7] [8].
Although there are some research that observed posterior ankle region of PAIS patients using MR or
radiographic, or arthroscopic image, but the study that observed posterior ankle image using ultrasonography are
less [3] [8] [9]. To our knowledge, this is the first study investigated the change of distance between tibia and
calcaneus in posterior ankle region by using ultrasonograpy.
The distance between tibia and calcaneus was shortened with increasing ankle plantar flexion angle
within the range from maximal dorsiflexion to maximal plantar flexion (men: 53.4±4.4 to 22.8±2.7 mm, women:
50.6±2.4 to 22.5±2.5 mm). As the hypothesis, the distance between the tibia and calcaneus is shorten as the
ankle plantar flexion angle increases. The shortening of distance between tibia and calcaneus might indicate the
findings of mechanism, which can cause posterior ankle impingement. There is a possibility that if some tissues
are entrapped between them, symptoms of PAIS occur [1] [3]. In this study, all participants had no history of
ankle injury before this measurement. Though some impingement may be observed dynamically in patients with
PAIS by ultrasonographic assessment.
In spite of healthy participants, the distance was not shortening significantly between 30° plantar flexion
and 45° plantar flexion, 30° plantar flexion and maximal plantar flexion, 45° plantar flexion and maximal plantar
flexion. It indicated that the distance between tibia and calcaneus was not shortened further after 30° plantar
flexion. Repetitive ankle plantar flexion is generally considered the risk factor of PAIS [1] [5]. Therefore, the
certain contact or impingement could have already occurred after 30° plantar flexion in the ankle posterior
region without any pain, and it may cause PAIS conclusively. It may be the mechanism to develop PAIS by
athletes to repeat the ankle plantar flexion.
Previously, a radiographic study reported that approximately 70% of total plantar flexion was
attributable to the talocrural joint, with the remaining 30% coming from motion between adjacent of the studied
foot bones [10]. For this reason, after the ankle plantar flexion angle was increased from 30° and distance
between tibia and calcaneus was no longer change, there was a possibility that the movement of the mid foot and
forefoot greatly affected, such as Talus-Navicular, Navicular-Cuneiform, and Cuneiform-Metatarsal joint.
Although this study gives many suggestions about the dynamics of the posterior ankle region due to the
movement of the ankle plantar flexion, there are some limitations in this study. The site just where PAIS really
occurs was out of the immediate sight by using ultrasonography. 3D-2D model registration techniques was used
to determine hind foot kinetics during the weight bearing activity from 20° dorsiflexion to 15° plantar flexion by
using fluoroscopic images [11]. However the posterior ankle kinetics of larger plantar flexion angle, such as

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

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

References
[1] Giannini S, Buda R, Mosca M, Parma A Di Caprio F. (2013). Posterior Ankle Impingement. Foot Ankle
Int 34(3), pp. 459-465
[2] Rathur S, Clifford PD, Chapman CB. (2009). Posterior ankle impingement: os trigonum syndrome. Am J
Orthop 38(5), pp. 252-253
[3] Robinson P, Bollen SR. (2006). Posterior ankle impingement in professional soccer players: effectiveness
of sonographicallyguided therapy. Am J Rad 187(1), pp. W53-58
[4] Sasadai J, Urabe Y, Maeda N, Shinohara H, Fujii E, Takai S. (2013). The effect of ankle taping to restrict
ankle plantar flexion on soccer instep kicks. Jpn J Clin Sport Med 21(3), pp. 694-701 (in Japanese)
[5] Lerch S, Kasperczyk A, Warnecke J, Berndt T, Rühmann O. (2013). Evaluation of Cam-type
femoroacetabular impingement by ultrasound. Int Orthop 37(5), pp. 783-788
[6] Robinson P. (2007). Impingement syndrome of the ankle. Eur Radiol 17(12), pp. 3056-3065
[7] van Dijk CN. (2006). Anterior and posterior ankle impingement. Foot Ankle Clin Am 11(3), pp. 663-683
[8] Calder JD, Sexton SA, Pearce CJ. (2010). Return to training and playing after posterior ankle arthroscopy
for posterior impingement in elite professional soccer. Am J Sport Med 38(1), pp. 120-124
[9] Peace KA, Hillier JC, Hulme A, Healy JC. (2004). MRI features of posterior ankle impingement
syndrome in ballet dancers: a review of 25 cases. Clin Radiol 59(11), pp. 1025-1233
[10] Russell JA, Shave RM, Kruse DW, Koutedakis Y, Wyon MA. (2011). Ankle and Foot Contributions to
Extreme Plantar-and Dorsiflexion in Female Ballet Dancers. Foot Ankle Int 32(2), pp. 183-188
[11] Yamaguchi S, Sasho T, Kato H, Kuroyanagi Y, Banks SA. (2009). Ankle and subtalar kinematics during
dorsiflexion-plantarflexion activities. Foot Ankle Int 30(4), pp. 361-366

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Influence of Difference in Knee Alignment on Site of Pain after

Walking

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

Abstract
【Background and study aim】In this study, focusing on the individual difference in the characteristics
of the knee joint, which plays an important role in weight bearing during walking, we examined the relationship
between difference in knee alignment and pain in the legs during walking.【Material/Methods】A total of 40
subjects, including 25 healthy men and 15 women were recruited to this study. Knee alignment was classified
according to the intercondylar and intermalleolar distances by increments of 2.0 cm. After walking (85km) on
day 3 of the 5-day event, subjects were required to answer a questionnaire asking where in the leg they had pain.
【Results】The following sites exhibited significant differences in the number and incidence of injury
between groups: the anterior side of lower leg (p <0.05), posterior side of lower leg (p <0.01), ankle joint (p
<0.05) and sole of foot (p <0.01). 【Conclusions】When performing an exercise that places load on the legs,
such as walking, one should consider the risk of injury by measuring the individual’s knee alignment before
commencing the exercise.
Keywords: genu varum, genu valgum, injury, overuse.

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

Methods

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

Investigation of post-walking pain

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

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

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

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Fig. 1 Comparison of incidence of disorders in different sites

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

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

Conclusion
Although a number of studies have been conducted on the effect and method of walking, none of these
studies has given detailed consideration to individual physical characteristics, which may be one of the factors
causing injuries and hindering the continuation of regular exercise. When performing an exercise that places load
on the legs, such as walking, one should consider the risk of injury by measuring the individual’s knee alignment
before commencing the exercise.
site of pain and knee alignment by determining whether the site of pain differs among subjects, using
the Kruskal-Wallis test. Significant differences were further assessed using a multiple comparison test.

References
[1] Hakim A.A., Curb J.D., Petrovitch H. et al. (1999). Effects of walking on coronary heart disease in
elderly men: the Honolulu Heart Program. Circulation 100, 9-13.
[2] Lee I.M., Rexrode K.M., Cook N.R., Manson J.E. Buring J.E. (2001). Physical activity and coronary
heart disease in women: is "no pain, no gain" passé? Journal of the American Medical Association 285,
1447-54.
[3] Manson J.E., Hu F.B., Rich-Edwards J.W. et al. (1999). A prospective study of walking as compared with
vigorous exercise in the prevention of coronary heart disease in women. The New England journal of
medicine. 341,650-8.
[4] Wang G., Zheng Z.J., Heath G., Macera C., Pratt M., Buchner D. (2002). Economic burden of
cardiovascular disease associated with excess body weight in U.S. adults. American journal of preventive
medicine. 23, 1-6.
[5] Macera C.A., Jackson K.L., Hagenmaier G.W., Kronenfeld J.J., Kohl H.W., Blair S.N. (1989). Age,
physical activity, physical fitness, body composition, and incidence of orthopedic problems. Research
quarterly for exercise and sport. 60, 225-33.
[6] Simonsen E.B., Dyhre-Poulsen P., Voigt M., Aagaard P., Sjøgaard G.., Bojsen-Møller F. (1995). Bone-
on-bone forces during loaded and unloaded walking. Acta anatomica. 152, 133-42.
[7] Wluka A., Forbes A., Wang Y., Hanna F., Jones G., Cicuttini F. (2006). Knee cartilage loss in
symptomatic knee osteoarthritis over 4.5 years. Arthritis research & therapy. 8, 90.
[8] Hurwitz D., Ryals A., Case J., Block J. and Andriacchi T. (2002). The knee adduction moment during
gait in subjects with knee osteoarthritis is more closely correlated with static alignment than radiographic
disease severity, toe out angle and pain. Journal of orthopaedic research 20, 101–107.
[9] Schipplein O.D. and Andriacchi T.P. (1991). Interaction between active and passive knee stabilizers
during level walking. Journal of orthopaedic research : official publication of the Orthopaedic Research
Society. 9, 113-9.
[10] Sogabe A., Mukai N., Shimojo H., et.al. (2003). A genu varum effects on each lower extremity muscle
activity during leg press exercise. Japanese Journal of Physical Fitness and Sports Medicine. 52, 275-284.
[11] Sogabe A., Mukai N., Shimojo H., et al. (2003). Genu varum effects on muscle hardness of lower limb
after leg press exercise. The Journal of Japanese society of clinical sports medicine. 11, 518-525.
[12] Abraham W.M. (1977). Factors in delayed muscle soreness. Medicine and science in sports. 9, 11-20.
[13] Armstrong R.B. (1984). Mechanisms of exercise-induced delayed onset muscular soreness: a brief
review. Medicine and science in sports and exercise. 16, 529-38.
[14] Cleak M.J., Eston R.G. (1992). Delayed onset muscle soreness: mechanisms and management. Journal of
sports sciences. 10, 325-41.
[15] Miles M.P., Clarkson P.M. (1994). Exercise-induced muscle pain, soreness, and cramps. The Journal of
sports medicine and physical fitness. 34, 203-16.
[16] Kettelkamp D.B., Wenger D.R., Chao E.Y., Thompson C. (1976). Results of proximal tibial osteotomy.
The effects of tibiofemoral angle, stance-phase flexion-extension, and medial-plateau force. The Journal of
bone and joint surgery. American volume. 58, 952-60.

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[17] Chao E.Y., Neluheni E.V., Hsu R.W., Paley D. (1994). Biomechanics of malalignment. Orthop Clin
North Am. 25, 379-386.
[18] Hewett T.E., Lindenfeld T.N., Riccobene J.V., Noyes F.R. (1999). The effect of neuromuscular training
on the incidence of knee injury in female athletes. A prospective study. The American journal of sports
medicine. 27, 699-706.
[19] Felson D.T., Zhang Y., Hannan M.T., et al. (1997).Risk factors for incident radiographic knee
osteoarthritis in the elderly: the Framingham Study. Arthritis and rheumatism. 40, 728-33.
[20] Powers C.M., Maffucci R. and Hampton S. (1995). Rearfoot posture in subjects with patellofemoral pain.
The Journal of orthopaedic and sports physical therapy. 22, 155-60.
[21] Mikulicz J. (1878). Ueber individuelle Formdifferenzen am Femur und an der Tibia des Menschen. Mit
Berucksichtigung de Statik des Kniegelenks. Arch Anat Entwicklungsgesch, 351.
[22] Donald A. (2002). Neumann Kinesiology of the Musculoskeletal System. Mosby Inc., St. Louis.

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Psycho-Social Factors Promoting Psychological Acceptance of

Athletic Injuries

Tatsumi T.1, Takenouchi T.2

1
Faculty of Education, KIO University, (JAPAN)
2
Research Center of Health, Physical Fitness and Sports, NAGOYA University, (JAPAN)
e-mail:[email protected]

Abstract
[Aim] Psychological acceptance of athletic injury is characterized by 2 perspectives: Self-Motivation (SM) and
Focus on the Present (FP). Factors related to developing psychological acceptance of athletic injury in athletes are in the
process of being clarified. The purpose of this study was to develop a scale based on 3 perspectives: Emotional Stability (ES),
Sense of Unity with the Team (SUT), and Temporal Perspective (TP), and to examine the relationship between these
psychosocial variables and psychological acceptance of athletic injury. [Methodology] Participants were student-athletes (N =
133) that had experienced injury-rehabilitation after entering university. They were asked to fill out an originally developed
questionnaire that consisted of the following scales: the Psycho-Social Factors Scale (PSF-S) based on three perspectives
extracted from interviews. Participants also completed the Athletic Injury Psychological Acceptance Scale (AIPA-S).
[Results] Factor analysis using the principal factor method and Promax rotation conducted on the 22 items of the PSF-S
extracted four factors: ES: α= 0.854, Self-competence in the team (SCT): α= 0.837, TP: α= 0.847, and Communication with
Teammates (CT): α = 0.822. Results of conducting a similar factor analysis on the AIPA-S extracted the two factors: SM: α=
890 and FP: α=.673. Next, the influence of the four PSF-S subscale scores on the two AIPA-S subscale scores was investigated
by conducting covariance structure analysis. Results of examining the model in relation to the path coefficient between
significance variables (p<.05) indicated the influence of SM in the following order: TP (0.50), ES (0.40), and SCT (0.11).
Moreover, the influence was FP was identified in the following order: ES (0.56), CT (0.20), and TP (0.14). The model also had
a high index of fit (χ2=1.82, df=3, n.s.; GFI=.995; AGFI=.968; RMSEA=.000). [Conclusion] It is important to constantly
monitoring the temporal perspective and emotional recovery process of injured athletes.
Keywords: Psychosocial factors, Athletic injury psychological acceptance, Promotion factor

Introduction
Psychological acceptance of athletic injury has been defined as the psychological state in which an injured athlete
recognizes the severity of an injury and tries to find ways of coping with the injury and rehabilitation (Tatsumi and Nakagomi,
1999). Two perspectives have characterized psychological acceptance of athletic injury: “Self-Motivation (SM)” and “Focus
on the Present (FP).” Tatsumi (2013) suggested a relationship between these two variables of psychological acceptance of
athletic injury and dedication shown for rehabilitation. SM indicates the degree to which an athlete understands and is aware of
the purpose and meaning of the rehabilitation that she/he is undergoing. FP indicates an athlete’s perception that she/he cannot

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currently play sports and is making a conscious effort during the rehabilitation process. Factors related to further development
psychological acceptance of athletic injury are still under investigation.
The purpose of this study was to develop a scale based on the three perspectives explicated by Tatsumi and
Nakagomi (1999): “Emotional Stability (ES)”, “Sense of Unity with the Team (SUT)”, and “Temporal Perspective (TP),” and
to examine the causal relationship between these psychosocial variables and psychological acceptance of athletic injury.

Method
1. Participants: It was predicted that the degree of injury and the level of dedication for sports would affect
the psychological effects of injury. Therefore, participants were recruited based on the following conditions.
Athletes that had experienced refraining from athletic activities for at least one week and had participated in athletic-
rehabilitation after entering university.
Athletes that had returned to athletic activities before at least one week, and were not currently undergoing athletic-
rehabilitation.
University student athletes in physical education departments that were inclined to do athletics and have a relatively
long career in athletics.
The selected participants were student-athletes (N = 133: Mean Age, 20.21 years, SD=1.07; Mean number of weeks
after stopping sports was 7.97, SD=11.26).
The Kio University Research Ethics Committee approved this study.
2. Questionnaires: The following questionnaires were used in the assessment.
1) Psychosocial Factors Scale (PSF-S): A provisional version of the PSF-S in which 24 items assessed the
there perspectives, ES, SUT, and TP described above.
2) Athletic Injury Psychological Acceptance Scale (AIPA-S): AIPA-S consists of 7 items measuring the level
of psychological acceptance of sports injury, composed of two subscales: Focus on the present and Self-motivation.
Tatsumi (2013) established the reliability and validity of this scale.
The response format for the PSF-S and AIPA-S were altered to the 7-point Likert scale ranging between 1 (not at all)
to 7 (very much). Participant that had two or more injury experiences in the past were requested to respond to the scale after
recollecting one injury experience that had left a deep impression on them.

Results
IBM SPSS 20.0 Statistics and Amos 20.0 was used for statistical analysis.

1. Reliability and Validity of the Scales:

Criteria for factor validity in the factor analysis described below were based on the Kaiser-Guttman rules. Selected
factors had an eigenvalue above 1.0, an absolute value of factor loading above 0.40, a high degree of commonality, and
appropriate content that fitted the factor name. Reliability was measured by calculating α coefficients using Cronbach’s
equation for internal consistency.

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（Psycho-Social
Table 1. Results of Factor
factor analyzing Psychosocial
） （Psychological Acceptance Factor ）
Factors Scale (PSF-S)
N=133）
（ Factor loadings
Communality
ES: Emotional stability
Factors and Items (α=.89) F1 F2 F3 F4
F1 Emotional Stability: ES (8 items: α=.85)
I don't hurry .19 .40 0.87 0.00 -0.10.64 -0.05 0.64
I don't feel pressure .56 0.72 -0.04 -0.08 -0.09 0.42
am not SCT:
I.42 Self-competence
in a hurry and try to begin in the own
at my teampace SM: Self motivation
0.71 0.04 0.10 -0.08 e1
0.55
.11
I am calm 0.63 -0.01 0.18 0.10 0.64
.44 I don't hesitate .39 0.60 0.07 0.17.57 -0.07 0.47
※ I am not imaginable of the future, and uneasy. .50 0.57 0.02 -0.04 0.11 0.38
am not C
I.28 T: Communication with teammates
shocked .20 FP: Focus
0.57
on the present
0.00 -0.18 -0.12 e2
0.21
※ It confuses my mind 0.51 -0.06 0.02 0.24 0.42
F2 Self-competence in the Team: .40SCT (5 items: α=.84) .14
The team leader understands me well 0.02
χ2 =1.82, df=3, 0.79 0.04 -0.25
n.s.; GFI=.995; 0.55
TP: T emporal perspective
My opinion is considered in team activities 0.00 RMSEA=.000
AGFI=.968; 0.77 -0.04 0.04 0.60
I think that I am a good team member -0.02 0.73 0.01 0.14 0.63
Figure
As the team leader, I can talk without 1. Covariance structure analysis Result 0.04 0.68 -0.12 0.02
constraints 0.44
I think of myself as a person needed by the team -0.02 0.62 0.13 0.08 0.50
F3 Temporal Perspective: TP (4 items: α=.85)
The goal is reached gradually -0.05 -0.08 0.87 -0.10 0.61
I try to work positively in my own way 0.00 -0.07 0.80 0.08 0.66
I will do what I can do for the team -0.12 0.12 0.76 -0.02 0.56
I try to begin with what is possible to do now in my own way 0.03 0.01 0.75 -0.01 0.58
F4 Communication with teammates: CT (5 item: α=.82)
I am satisfied with my interpersonal relationships with teammates -0.10 -0.15 -0.03 0.96 0.74
I am satisfied with the relationship with my teammates 0.06 -0.04 -0.06 0.78 0.59
I have the colleague who tells worry in the team -0.13 0.10 0.05 0.63 0.43
My team values players with an individual will -0.03 0.31 -0.08 0.52 0.43
I can adapt myself to the interests of the team 0.27 0.04 0.14 0.44 0.51
Correlation coefficient F1 - 0.21 0.55 0.46
F2 - - 0.34 0.40
F3 - - - 0.47
※Reversing score item

Table 2. Factor analysis result concerning Athletic Injury Psychological Acceptance Scale (AIPA-S)
（N=133） Factor loadings
Communality
Factors and Items (α=.86) F1 F2
F1 Self-Motivation: SM (3 items: α=.89)
I understand what I need to do to move forward 1.01 -0.13 0.87
It is clear to me what I have to do now 0.93 -0.03 0.82
I have come to terms with the past and am focused on the present 0.63 0.18 0.57
F2 Focus on the Present: FP (3 items: α=.67)
※ I want to run away from my current situation -0.08 0.71 0.43
※ I am still worrying about the past and cannot move forward -0.03 0.61 0.35
I don't have any worries and am positively accepting my current situation 0.31 0.49 0.54
(Remainder Item)
I am clarifying what I can do now and what I cannot do and planning ahead 0.35 0.39 0.47
Correlation coefficient F1 - 0.67
※Reversing score item

PSF-S: As a result of item analysis based on I-T correlation and G-P analysis, the validity of 23 items, with the
exception of item 7 (Feelings are strained) was confirmed. Next, factor analysis using the principal factor method and promax
rotation was conducted, which indicated that ‘PSF-S’ consisted of 4 factors: ES: α=0.85, Self-competence in the team (SCT):
α=0.84, TP: α=0.85, and Communication with teammates (CT): α=0.82 (Table 1). These results suggested the effectiveness of
the approach separately for the two factors: Communication with teammate, indicating the recovery of communication based
on affirmative feelings of teammates, as well as Self-competence in the team, indicating recovery of self-competence for team
management and for the relationship with coach, which is related to the perspective of Sense of unity with the team that was
assumed when the scale was first envisaged.
AIPA-S: Similar to a previous study (Tatsumi, 2013), factor analysis using the principal factor method and promax
rotation indicated that ‘AIPA-S’ consisted of two factors, SM: α=0.89 and FP: α=0.67 (Table 2).
The results of the statistical tests fully support the reliability and factorial validity of PSF-S and AIPA-S.

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2. Psycho Social Factors promoting Athletic Injury Psychological Acceptance

The influence of the four subscale scores of the PSF-S on the two subscale scores of AIPA-S was examined by
conducting a covariance structure analysis. It was assumed that there was a covariance between the four PSF related to
exogenous variables. Moreover, it was assumed that there was a covariance between the errors of each variable related to the
degree of the correlation (r=0.58, p=0.00) between the SM factor and the FP factor related to AIPA-S of endogenous variables.
Analysis was repeated until goodness of fit continuously reached the highest value by deleting non-significant paths. As can be
seen in Figure 1, the goodness of fit index of the model was high (χ2(3)=1.82 (n.s.), GFI = 0.995, AGFI = 0.968, RMSEA =
0.000). Results of examining the model in relation to the path coefficients between significance variables (p<.05) related to SM
indicated the degree of influence in the order of TP (0.50), ES (0.40), and SCT (0.11) and related to FP in the order of ES
(0.56), CT (0.20), and TP (0.14). The relative comparison of the path coefficients suggested that "ES" strongly promoted an
AIPA focus, and "TP" strongly promoted SM related to AIPA. It is concluded that ES and TP related to PSF promote AIPA.

Conclusion
It is important to constantly monitoring the temporal perspective and emotional recovery process of injured athletes.

References
１) Tatsumi T, Nakagomi S: A study on psychological acceptance to injury in athletes: Analysis from the viewpoint of
athletic-rehabilitation behavior. Japan Journal of Sport Psychology, 1999, 26: 46-57.
２) Tatsumi T: Development of athletic injury psychological acceptance scale. Journal of Physical Therapy Science, 2013,
25: 545-552.
３) Ryan RM, Deci EL: Overview of self-determination theory: An organismic dialectical perspective. In: E.L. Deci and
Ryan (Eds): Handbook of self-determination research. University of Rochester Press, 2002, 3-33.

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Association between altered pelvic tilt and

hamstring strain among rugby palyers
(case in kandy district, Sri Lanka)

Wickramasinghe Y.M.N.M, Buddhika W.H.S.W.R, Paththuwage R.G,

Weerasinghe W.C.S, Wijayalath W.P.L.K, Udyakumari A.D.M.
Faculty of Allied Health Science, University of Peradeniya, Sri Lanka

Summary
Rugby is a contact sport which involves many lower limb movements. Lower limb injuries account for
over 50% of all injuries and hamstring injuries are the second most common injury among rugby players. As this
injury reduces the performance of the players, early diagnosis and taking remedial measures are of paramount
importance. This study used a convenient sample of 180 school rugby players and 6 of them were excluded
during the exclusion process. A field survey and specific orthopedic assessments were held to collect data and
Chi- Square test was used as analytical tools. It was found that, 57% and 4% of the players are with anterior and
posterior pelvic tilt respectively. Of the players, 13% were with hamstring strain. Based on the results, it is also
possible to conclude that hamstring strain holds no direct association between either form of pelvic tilt (P<0.01).
However, as this study did not consider the behavioral and environmental factors repeating the study
incorporating those aspects is recommended.

Introduction
The muscle contraction is the mechanism that provides energy for the movements of the body. Any
problem in muscle contraction will reduce the physical efficiency of human beings. Similarly, hamstring strain is
an injury to any muscle or tendon in hamstring group which could reduce the performance of humans and it
specially affects rugby players as it is a sport which involves many lower limb movements. Thus, early diagnosis
of the problem and taking remedial measures are of paramount importance.

Hamstring Muscles
Hamstring muscles are combination of three muscles (i.e. Semimembranosus, Semitendinosus and
Biceps Femoris) contains a high proportion of fast twitch type II muscle fibers. All muscles are attached
proximally to the ischial tuberosity except for the short head of biceps femoris which is originated at the linea
aspera and lateral supracondylar line of the femur. Semitendinosus is attached to the medial surface of the
superior tibia, semimembranosus to the posterior aspect of the medial condyle of the tibia and the oblique
popliteal ligament, while biceps femoris is attached to the lateral side of the fibula. Semitendinosus,
semimembranosus and long head of biceps femoris are innervated by the tibial division of the sciatic nerve and
the short head of the biceps femoris is innervated by common fibular nerve. Bicep femoris flexes the leg at the
knee joint, extends and laterally rotates the thigh at the hip joint and laterally rotates the leg at the knee joint.
Semimembranosus and Semitendinosus flexes the leg at the knee joint and extend the thigh at the hip joint,
medially rotate the thigh at the hip joint and the leg at the knee joint (Richard et,al,2007).
When workload exceeds the tolerance level of hamstring muscles it causes injuries to this muscle /
tendon and is known as Hamstring Strain and this is the second most injury reported by the rugby players
(Gibbs, 1994). According to, Opar et. al (2012), Hamstring Strain could also be occurred due to anatomical
factors such as biarticular organization, duel innervation of biceps femoris, fiber type distribution, muscle
architecture, poor lumbar posture and the degree of the anterior pelvic tilt and other possible reasons are age,
previous injuries, inadequate fitness, lack of proper worm up, strength imbalances between quadriceps and
Hamstring muscles, reduced Hamstring strength and endurance, lack of Hamstring and quadriceps flexibility,
reduced strength and coordination of pelvic and trunk muscles, inadequate eccentric hamstring strength to
counteract concentric quadriceps action in terminal swing phases of running, fatigue and postural abnormality.
Therefore, under stressful and rapid situations like sports, when a muscle failed in performing a particular action,

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the muscle could be subjected to damages. The Biceps femoris is the muscle that is often subjected to damages
and such damages, based on the clinical features can be categorized as grades I, II and III (Brotzman and Kewin,
2003).

Pelvic Tilt
Normally the Anterior Spuerior Illiac Spine of the pelvis line is on a horizontal line with the Posterior
Spurior Illiac Spine and on a vertical line with the Symphysis Pubis, and any deviation from the normal position
will cause an altered pelvic tilt (anterior or posterior). So, the altered pelvic tilt is a motion of the entire pelvic
ring in the sagittal plain around a coronal axis. The normal ranges of anterior pelvic tilt for males and females are
9.6 ± 3.5 and 11.0 ± 3.8 respectively (Mckeon and Hertel, 2009). As long as this angle is within the normal
range, the movement is considered as a normal anterior pelvic tilt and any deviation beyond that range is
considered as an altered pelvic tilt. The abnormal anterior pelvic tilt is resulted from one of the combinations of
tight hip flexors or erector spinae muscle and weakened and lengthened abdominal or hamstring muscle.
Anterior pelvic tilt produces hip flexion. In hip flexion the Anterior Superior Iiliac Spine moves interiorly and
the inferiorly while sacrum moves further from femur.
Any angle of posterior pelvic tilt is considered as an altered pelvic tilt (Levangie and Norkin, 2005).
The abnormal Posterior Pelvic Tilt is resulted from one of the combinations of the combinations of tight
abdominals or hamstring muscles and /or weakened and lengthened hip flexors or erector spine muscles (Lippert,
2006). Posterior pelvic tilt produces hip extension. In hip extension symphysis pubis moves up and the sacrum
comes closer to the femur.
As altered pelvic tilt, especially the degree of anterior pelvic tilt is categorized as a risk factor for
hamstring strain many studies were focused on the association of hamstring extensibility and length with pelvic
position, but none has paid attention to the relationship between the Hamstring Strain and altered pelvic tilt.
Since the altered pelvic tilt is having negative impacts on hamstring muscle, objectives of this study
were to determine the frequency of occurrence of anterior pelvic tilt and posterior pelvic tilt among rugby
players and to examine whether the anterior pelvic tilt and posterior pelvic tilt of rugby players were associated
with hamstring strain.

Material and method

A convenient sample of 180 rugby players above 17 years of age were selected from 8 schools in Kandy
district as it is the most famous district for rugby. During the exclusion process 6 players were dropped and the
balance 174 was used in the research. Detailed physical assessments done examining the clinical performance of
the players and using specific orthopedic tests ( Passive Straight Leg Raising Test, Resisted Knee Flexion,
Slump Test and Sit and Reach Test). The range of motion of lower limb joints, muscle power around hip and
knee joint muscles and angle of pelvic tilt were also recorded. Meter stick, Goniometer and caliper were the
instruments used in taking measurements of the players.
The meter stick trigonometric method suggested by Sanders and Stavrakas (1981) was used to measure
the angle of pelvic tilt. Reliability of this method had proven and thus, it is an acceptable method. The
trigonometric procedure used is explained below.

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The range the motion was measured positioning the patient and placing the goniometer over the
accurate point on each joint and the stable and movable arms of the goniometer aligning according to the
slandered method. Muscle strength was measured using the Manual Muscle Testing technique.

Results and conclusions

Results revealed that, 57 % and 4% of the players were with anterior and posterior pelvic tilt
respectively. Thus, it is possible to conclude that anterior pelvic tilt is more common among rugby players. One
of the research hypotheses was that there is no association between hamstring strain and anterior pelvic tilt. The
Chi- square test at 0.01% level of significance was used for this purpose. Calculated value of the Chi-square was
0.48 and that was smaller than the critical value (6.63) and therefore the hypothesis was accepted. It indicates
that, anterior pelvic tilt and hamstring strain are not associated. The next hypothesis tested was there is a
relationship between posterior pelvic tilt and hamstring strain, Chi- square test at the same level of significance
was used for this purpose too. The calculated and critical values of Chi- square were 3.99 and 6.63 respectively.
Therefore it is possible to state that there is no statistical evidence to reject the null hypotheses at 0.01 % level of
significance. Finally, based on the results, it is concluded that neither anterior pelvic tilt nor the posterior pelvic
tilt is associated with hamstring strain.
As this study did not consider the behavioral and environmental factors of the players it is suggested to
repeat the study incorporating those aspects.

References
BROTZMAN,S.B AND WILK, K.E. Clinical Orthopedic Rehabilitation (2nd edition ) Philadelphia: The Curtis
Center, Pennsylvania. 2003.
GIBBS, N, Common Rugby League Injuries; Recommendations for Treatment and Preventive Measures. Sports
Med. 18 (6): 67 – 81.1994
LEVANGLE, P.K AND NORKIN ,C.C. Joint Structure and Functions: A Comprehensive Analysis. (4th edition).
Philadelphia: F.A.Davis Company.2005.
LIPPERT, L.S. Clinical Kinesiology and Anatomy (4th edition). Philadelphia: F.A.Davis Company.2006
MCKEON, J.M.M. AND HERTEL, J. Sex Differences and Representative Values for Lower Extremity
Alignment Measures. Journal of Athletic Training, 44 (3):249- 55. 2009.
Opar, D.A, Williams, M.P, and Shield, A.J. Hamstring Strain Injuries; Factors that lead to Injury and Re-injury.
Sports Med. 42(3):209- 26. 2012.

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The effects of musical tempo during cycling exercise

among undergraduate sport science students

Illias N.F., Adnan R., Ross V., Sulaiman N., Appukutty M.

Rahmat ADNAN
Accredited Exercise Physiologis - Faculty of Sports Science & Recreation - Universiti Teknologi MARA Shah
Alam - Malaysia
Email: [email protected] / [email protected] - Telephone: 60355211893 Fax: 60355442910

Abstract
This study was conducted in order to investigate the effects of different musical tempo during cycling
exercise. Twenty male undergraduate sport science students’ with mean age: 21.60 ±1.60 years, weight: 63.35
±7.80 kg, height: 170.32 ±5.92 were voluntarily participated in this study. All subjects were involved into
experimental studies using aerobic cycling exercise; fast and slow musical gamelan tempo and no music group
respectively. The cycling exercise group was evaluated using following parameters: Heart rate, rating
perceived exertion (6-20 Borg scale), feeling scale, distance pedalled and handgrip strength. Participants were
completed cycling for 20 minutes at self-paced intensities. Wilcoxon Signed Ranks Test was used to measure the
outcomes of this study due too small samples size. The result of this study found heart rate was significant higher
when listening to fast musical gamelan tempo compare to slow musical gamelan tempo. Furthermore, RPE
scale was significant higher when listen to fast musical gamelan tempo compare to no music. Moreover, feeling
scale was good when listening to fast musical gamelan tempo compare to slow musical gamelan tempo and no
music. Listening to no music was increase the distance pedalled when comparing to the slow musical gamelan
tempo and no significant effect listening to fast musical gamelan tempo. Hence, this study suggests listening to
fast musical gamelan tempo may influence or enhance the aerobic cycling performance.
Keywords: Fast musical gamelan tempo, slow musical gamelan tempo, heart rate (HR), rating
perceived exertion (RPE), feeling scale (FS), distance pedalled (DP).

Research Background
Presently, Waterhouse, Hudson, and Edwards (2010), suggested music can cause positive effects when
listening at the same time of physical activity is performed. Thus, listening to the music during exercise maybe
can enhance the individual to cope more efficiently with exercise modalities and with specific exercises that
eliminate or evoke feeling of pain (Koç & Curtseıt, 2009). According to the Kelly and Kristal (2010), many
fitness instructors considered the addition of music during exercise give similar effect like ergogenic effect on
performance.
Music can be inspirational to some people because music provide an important beneficial effect to the
exercise and sport experience (Kelly & Kristal, 2010). In fact, with the current technology exist such as MP3
players, I-Pod and Zunes, music and more make people are more accessible and convenient using this device
while exercise (Kelly & Kristal, 2010). Besides that, music proven can increase enjoy and happy arousal of
individual when engage with group session of exercise such as aerobic dance, Yoga, Pilates and etc (Kelly &
Kristal, 2010).
Moreover, past studies found music had narrows a performer’s attention and divert the sensation of
fatigue to excitement mood during exercise. In addition, they also reported music enhanced the positive
dimensions of mood and alters the temper from negative dimensions to positive dimension. According to
Mohammadzadeh, Tartibiyan, and Ahmadi (2008) their study summarized that music can alter psychomotor
arousal eventually can act either as a stimulant or sedative.
Previous studies by Karageorghis et al.,(2009), its showed that by using motivational synchronous
music can elicit an ergogenic effect and enhance in task effect during an exhaustive endurance exercise.
According to Attila Szabo (2004), it proved while listened to slow musical tempo it decrease the quality of the
training. In contrast, they also reported, listening to the fast musical tempo boost the quality of training. This
similar to the studies by Seath and Thow (1995) and A. Szabo, Small and Leight (1999), when listening to fast
musical tempo while performing aerobic exercise it made positive feeling state.

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In contrast, some study was declared when listening to the fast musical tempo does not enhance the
exercise performance. According to Copeland and Franks (1991), reported in study conducted by Koç and
Curseit (2009), listening to the loud and fast musical tempo did not enhance physiological and psychological
responses during submaximal exercise. For instance, according to Schwartz et al., 1990, reported in the study
conducted by Ghaderi, Rahimi, and Ali Azarbayjani (2009), listening to the music while performing the exercise
did not affected the exercise performance.

Research Objective
1.1 To compare the effects of different musical tempo listened between fast, slow musical tempo and no
gamelan tempo (no music) during cycling exercise on heart rate (HR), rating perceived exertion (RPE),
feeling scale (FS) and distance pedaled (DP).
1.2 To compare the effects of different musical tempo listening between fast, slow musical tempo and no
gamelan tempo (no music) during physical strength.

Method
Participants: Twenty undergraduates male students were required to take part in two experimental
conditions: fast and slow musical gamelan tempo and no music (control group). At least 48 hours later a second
cycling session was performed by each participant. This case is to make a comparison between two treatments
given and one control group. This is to determine whether there was a significant difference when listened to the
difference musical tempo and no music during cycling exercise and physical strength.
Sampling technique: This study used purposive sampling technique for only 20 participants from
UiTM undergraduates sport science students that actively involved in physical activity at least three times per
week with age range between 20 to 26 years of age
Research design: This study used quasi-experimental design to achieve its objective. Twenty
undergraduates male students were undertaken into two experimental studies: fast musical gamelan tempo, slow
musical gamelan tempo and no music (control group). None of the participants were involve in regular
medication, musculoskeletal injury and cardiovascular disease prior of this study. Professional cyclists that
represented for state or national team were excluded from this study.

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Figure 1: Conceptual research framework

Undergraduate Sport Science students from UiTM Shah

Active healthy male students

20 participants

Physical strength Cycling

Listening the fast musical Listening the fast musical gamelan

gamelan tempo while performing tempo while cycling 20 minutes
handgrip strength test

Rest at least 48 hours

Rest for 30 seconds between trails

Listening the slow musical Listening the slow musical gamelan

gamelan tempo while tempo while cycling 20 minutes
performing handgrip strength

Rest at least 48 hours

Rest for 30 seconds between trails

Listening the no music while cycling

Listening the no music while
20 minutes
performing handgrip strength
test

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Outcome measures: This study aims to investigate the acute effect of musical tempo during cycling
exercise. Therefore, this study encompasses three different musical tempos between four dependent variables of
outcomes measure during cycling exercise. The outcomes measures are exercise heart rate, rate perceived
exertion, feeling scale, rate of pedal cadence and handgrip strength (Figure 2):

Figure 2

Dependent variables

Independent variables

1. Exercise Heart Wilcoxon

rate Signed
2. Exercise RPE Ranks Test
Musical tempos – 3. Exercise Feeling
fast, slow and no Cycling
scale RESULT
music. exercise
4. Rate of cadence
5. Handgrip strength

Instrumentation: Climatic chamber in UiTM Shah Alam was used to maintain the room temperature
for this study. Throughout the study environment within the laboratory remained at room of temperature 26 - 29°
C. Testing equipment and scoring procedure were calibrated and set up before the test begin .
This study was used Monark Pendulum Cardio Care 827 E (made in Sweden). Monark Cardio Care 827
E measure a total distance pedalled by the each participant during 20 minutes of cycling exercise. Participant’s
listened to special tempo-composed of gamelan music during their cycling sessions using MP3 player Philips
(GoGear) and a headphone (Ultimate technology HM-550). A stopwatch was used to set and record the duration
of cycling time.
Heart rate watch and monitor (RS-100 Polar) were used to record the activity of the heart beat at
constant rate of cycling exercise. Moreover, perceived rating exertion (RPE) Borg 20 scale and feeling scale (FS)
by Hardy and Rajeski, 1989 was used as additional parameter of this study.
Music composition: This study used cross-discipline research with researcher from Faculty of Music
UiTM for special tempo composition using gamelan melody by Associate Professor Dr. Valerie Ross.
Furthermore, the use of this gamelan-tempo is to measure heart rate, rating perceived exertion, feeling scale and
distance pedalled during cycling exercise.
In this study, each of the 20 participants exercised for 20 minutes per session for a total of 3 sessions. In
the first session they listened to digital gamelan music (‘saron’) played using only 4 pitches in fast tempo
(‘allegro’ at 138 beats per minute). In the second session they listened to digital gamelan music (‘saron’) played
using only 4 pitches in slow tempo (‘adagio’ at 60 beats per minute). The third session represented the control
group where there was no music played during exercise session..
The music was composed using sound samples recorded at 44.1kHz and at a sample rate of 16 bits.
Each sample was recorded individually on the Korg Krome keyboard which was then patched into ProTools 9.
The sound used to achieve this gamelan sound that was closest to the ‘Saron’ was called the 'Gamelon' in the
keyboard settings.
Each sample was recorded once, and then repeated over and over again in order to reach the required
20 minutes of playback. Each sample was the compressed and normalized to ensure that there were no blips and
clicks that could potentially compromise the quality of the recording. After all necessary samples were recorded,
they were transferred into WAV format which was then further compressed into MP3 format.
Pre- test procedure: Prior of the test, all participants completed basic pre-test assessments. These
includes signed in consent form and pre- screening for risk stratification using SMA-HMS UQ. Besides, the
researcher take an opportunity to brief the participant clearly about the framework of the test is conducted. This

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includes; protocol and procedure to handle the test equipment and tools using Monark Cardio Care 827 E, Rating
Perceived Exertion (RPE) and feeling scale (FS).
The basic demographic profiles were taken such as weight (kg), height (cm) and age (year) during prior
of this study. Furthermore, to ensure the proper cadence during the paddling the bike, each participant was
informed to select their hip height level for cycling sitting height (ACSM 2006). All participants were instructed
to wear the heart rate transmitter at the left side of the chest for constant Heart Rate monitoring during the test
was conducted.
The heart rate maximum (HRmax) was calculated for each participant using age estimate equation (220
- age) as a baseline data. The training heart rate zone of the test was set up intensity from 55% to 69% HRmax
based on the ACSM recommendation for moderate intensity. Resting heart rate was recorded in order to obtain
the most valid moderate intensity which is in range 55% to 69% HRmax using Karvonen method. Training heart
rate zone was calculated using Karvonent method equation [RHR + % intensity × (HR max - RHR)].
All participants were remained to refrain from heavy meals and stimulants such as caffeine substances
for at least 4 hours prior to testing. In addition, participants were asked not to do heavy exercise 24 hours before
the test session.
Experiment procedure: All the participants were performed three sessions adopted from Elliott et al
2005 protocol: fast and slow musical gamelan tempo and listen to no music. Schedule for the participants to
perform the test was made. For the first session, all the participants had heard fast musical gamelan tempo, the
second session all participants had heard slow musical gamelan tempo and the third session participants did not
hear any music.
Each participant had been given time to perform 3 minutes warm up at a cadence of 50 repetition per
minute (rpm), with resistance 1kp. Once the test protocol performed, participant was listened to the fast musical
gamelan tempo using portable music device which is MP3 players Philips (GoGear) with headphone (Ultimate
technology HM-550) at the standardise volume.
After warm up session, the test protocol begun. Participant was pedalled the bicycle at their self selected
speed and gradient for 20 minutes. Participant’s heart rate (HR), rate perceived exertion (RPE), feeling scale
(FS) and distance pedalled (DP) were recorded during 5 min, 10 min, 15 min and 20 min cycling. No
encouragement or any other type of communication was given to the participants while they were cycling.
Completion of the 20 minutes test was followed by a 3 minutes cool down performed at self selected intensities.
The next two sessions continued with the same protocol but listened to slow musical gamelan tempo and listen to
no music as a control group after rest at least 48 hours.

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Figure 3: Data collection procedure

3 minute warm up at a cadence of 50 repetitions per

minute (rpm), with resistance 1kp

Cycling for 20 minutes and HR, RPE, FS and

Distance was recorded four times (5 min, 10 min, 15
min, 20 min)

When test begun, participant was pedaled at self

selected speed and cadence base on their preferable
effort

Once the test protocol performed, the participant

listened to the music using portable music device
which is MP3 players with headphone

Completion of 20 minutes cycle ergometer test,

followed by 3 minute cooling down, perform at a
self selected intensity and speed

Statistical analysis: This study utilized different group for two experimental conditions and one control
group. Two experimental groups enrol fast and slow musical gamelan tempo and the control group listen to no
music during the experiment. An alpha of p<0.05 was set for all statistical test.
Descriptive statistics were calculated for all dependent variables. SPSS statistical software version 16.0
was used (SPSS Inc., Chicago,IL,USA) to analyze the data. The participants are lower than 30 (<30) in which
according to Central Limit Theorem (CLT) lead to a non-normal distribution. For that matter, researcher was
using the non-parametric test which is the Wilcoxon Signed- Rank test as an alternative for paired t test for
parametric test.

Result

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This study used the Wilcoxon Signed-Rank Test as the nonparametric test equivalent to the dependent t-
test. It is used to compare two sets of scores that comes from the same participants. Median score was used to
know which musical tempo most affect the performance. The basic statistical parameters for all the data were
also calculated: mean and standard deviation. The data was processed by means of the SPSS 16.0 statistical
program.

Article 1_Table 1: Demographic factors of the participants

N Mean SD

Age (Years) 20 21.60 1.60

Body weight (kg) 20 63.35 7.80
Body height (cm) 20 170.32 5.92

Article 1_Table 2: Mean and SD score for HR, RPE, FS and distance pedalled

HR RPE FS DP Physical
strength

Mean SD Mean SD Mean SD Mean SD Mean SD

Fast 5.23 2.27 33.7 7.02 18.7 8.49 15.5 3.13 39.24 6.16
musical
gamelan
tempo
Slow 4.33 1.44 30.6 7.03 14.6 6.24 14.9 2.73 39.35 6.78
musical
gamelan
tempo
No music 4.76 1.99 30.1 6.49 14.5 5.26 16.5 1.71 39.05 6.21
HR RPE FS DP Physical
strength

Fast musical 4.00 32.87 17.12 15.35 38.65

gamelan tempo
Slow musical 3.50 30.62 13.87 14.08 39.35
gamelan tempo
No music 3.50 30.65 15.37 16.86 40.20

Article 1_Table 3: Median score for HR, RPE, FS and distance pedalled

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Article 1_Table 4: Mean heart rate (HR)

Z score Asymp. Sig. (2- tailed)

Fast musical gamelan tempo vs. slow musical - 2.006 0.045

gamelan tempo

Fast musical gamelan tempo vs. no music -0.881 0.378

Slow musical gamelan tempo vs. no music -1.172 0.241

Heart rate (HR): It was the intention of the researcher to assess HR. Base on Wilcoxon Signed Ranks
Test showed that there were significant effect when comparing fast musical gamelan tempo vs. slow musical
gamelan tempo which is (Z = - 2.006, P = 0.045). Base on median score, participants was preferred to listen to
the fast musical gamelan tempo compare to slow musical gamelan tempo. But when compare to fast musical
gamelan tempo vs. no music and slow musical gamelan tempo vs. no music showed that there is no significant
different which are (Z = - 0.881, P = 0.378) and (Z = -1.172, P = 0.241).

Article 1_Table 5: Mean rating perceived exertion (RPE)

Z score Asymp. Sig. (2- tailed)

Fast musical gamelan tempo vs. Slow - 1.873 0.061

musical gamelan tempo
Fast musical gamelan tempo vs. no music -1.923 0.054
Slow musical gamelan tempo vs. no music -0.564 0.573

Rating perceived exertion (RPE): Base on Wilcoxon Signed Ranks Test showed that there was
significant effect when comparing fast musical gamelan tempo vs. no music which is (Z = - 1.923, P = 0.054).
Participants more preferred to listen fast musical tempo music compare to no music base on median score. There
is no significant effect of different musical tempo listen toward rating perceived exertion when comparing fast
musical gamelan tempo vs. slow musical gamelan tempo, (Z = - 1.873, P = 0.061) and slow musical gamelan
tempo vs. no music (Z = -0.564, P = 0.573).

Article 1_Table 6: Mean feeling scale (FS)

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Z score Asymp. Sig. (2-

tailed)
Fast musical gamelan tempo vs. Slow -3.125 0.002
musical gamelan tempo
Fast musical gamelan tempo vs. no - 2.147 0.032
music
Slow musical gamelan tempo vs. no -0.174 0.862
music

Feeling scale (FS): Base on Wilcoxon Signed Ranks Test showed that there were significant effect
when comparing fast musical gamelan tempo vs. slow musical gamelan tempo which is (Z = - 3.125, P = 0.002)
and fast musical gamelan tempo vs. no music which is (Z = - 2.147, P = 0.032). That means, participants like to
listen to fast musical gamelan tempo when compare to slow musical gamelan tempo and no music. There were
no significant effect when listen to different musical tempo toward feeling scale when comparing slow musical
gamelan tempo vs. no music which is (Z = - 0.174, P = 0.862) and median score indicate slow musical gamelan
tempo spoiled feeling scale compare to no music.

Article 1_Table 7: Mean distance pedalled (km)

Z score Asymp. Sig. (2- tailed)

Fast musical gamelan tempo vs. Slow -0.805 0.421

musical gamelan tempo

Fast musical gamelan tempo vs. no - 1.307 0.191

music
Slow musical gamelan tempo vs. no -2.147 0.032
music

Distance pedalled (km): Base on Wilcoxon Signed Ranks Test showed that there were no significant
effect when comparing fast musical gamelan tempo vs. slow musical gamelan tempo which is (Z = - 0.805, P =
0.421) and fast musical gamelan tempo vs. no music which is (Z = - 1.307, P = 0.191). But there were significant
effect when listen to different musical tempo toward feeling scale when comparing slow musical gamelan tempo
vs. no music which is (Z = - 2.147, P = 0.032). Median score shows that participants distance pedalled was
farther during no music compare to slow musical gamelan tempo.

Discussion
The most interesting finding in this study was significant different when listening to the two different
gamelan tempo and no music while performing cycling exercise towards HR, RPE, FS and PD.
Heart rate (HR): Analysis for the heart rate after twenty minutes cycling got favourable result. It was
found that, there were significant effects when listening to fast musical gamelan tempo compare to slow musical
gamelan tempo. Base on the median score, it demonstrates, participants were preferred to listened fast musical
gamelan tempo. There was no significant effect when comparing fast musical gamelan tempo with no music,
also slow musical gamelan tempo and no music.
Finding of the present study indicated, when listening to fast musical gamelan tempo participants
preferred to work above the moderate intensity which is 55% to 69% HRmax that was setting by researcher. It
can be concise that when listening to the fast musical gamelan tempo, participants were become more energetic
and motivated to do cycling exercise. Hence, heart rate score was above the training heart rate zone for moderate
intensity.

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This study was supported by the previous researcher. According to Karageorghis et al. (2009) when
listening to fast musical tempo music which is >120 beat per minute considered as motivational music, it
showed, participants heart rate were reached 193 beat per minutes which closed to the maximum heart rate. This
finding also support by Birnbaum et al. (2009) which was significant increase in heart rate when participants
listened to fast musical tempo during exercise. This finding also supported by Waterhouse et al. (2010) which by
increased the beat musical tempo listened, mean for heart rate was increase 0.1% compare to the decreased beat
musical tempo listened, mean score for heart rate was decrease 2.2%.
Heart rate finding in this study was contras to those reported by Young et al. (2009) as they said the
heart rate was unaffected when listening to the music during exercise. According to Nicola A Schie (2008), it
also shows that, the heart rate was unaffected when listening to the music when perform by professional cyclist.
A possible reason for this contrast finding was differences in type of participants. Perhaps professional cyclists
were more internally motivated and not focus on external stimuli. For this study, participants selected were
active person and not professional cyclists that represented for state or national team. Possibly this study have an
effect when listening to the music during cycling exercise because of the participants were sedentary people,
who only involved at least three times per week.
High intensity training also was results unaffected on heart rate (Young et al., 2009). Their studies
shows music was affected the cycling performance when it is done at moderate intensity. According to Rajeski
(1985) in study conducted by Elliott et al. (2005) they suggested, working at high intensities reduced the impact
of external stimuli. Consequently, for the present study, it is the possible factor there was an effect on heart rate
because the researcher was set for moderate training heart rate zone. According to Ghaderi et al. (2009), at the
lowest intensities, external cues such as music may become influential.
Rating perceived exertion (RPE): Finding indicated listening to fast musical gamelan tempo was
significant effect when compare to no music. Base on median score, participants were preferred to listened fast
musical gamelan tempo compare to no music. This is because, when listen to fast musical gamelan tempo,
participants become more energetic and aggravated to increase their exercise intensities. Participants were
preferred to increase their intensities those causes the increase the RPE scale. This finding supported by
Waterhouse et al. (2010) as they indicated, when increase by 10% tempo listen from the normal tempo, mean
score for RPE had increased 2.4 %.
Finding for present study also shows the same finding reported by Ghaderi et al. (2009) as they indicate,
RPE scale was lowered when listening to relaxation music when compare to motivational music. According to
Karageorghis et al. (2009), motivational music was determined when the tempo was >120 beat per minute.
Finding for present study also show the same finding reported by Karageorghis et al. (2009), there were benefits
derived from walking in synchrony with motivational music when compare with control condition.
Finding from present study was contrast to the study conducted by Nicola A Schie (2008). Finding from
their study shows that, RPE scale was decreased when listen to the music. This is because of the participants
selected were highly trained and disciplines cyclist. Similar finding reported by Young et al. (2009) when using
professional participants, listening to music did not affect the athlete’s RPE during treadmill exercise.
Once again this may be related to the type of participants were selected. Assumption that can be made,
athlete or professional cyclists were internally motivated. This finding also because, when performing the test, it
did not challenge professional cyclist fitness level. As we notice that, athlete or professional cyclists training
intensity was higher in order to maintain their performance. Therefore it might be the test was not challenging
their fitness level and that reason RPE score was lower.
Feeling scale (FS): Participant’s feeling scale revealed that was significant effect when cycling while
listen to fast musical gamelan tempo when comparing to slow musical gamelan tempo and no music. Base on
median score, it shows, those participants were preferred to listen to the fast musical gamelan tempo. According
to Seath and Thow (1995) in research conducted by A. Szabo, Small, and Leigh (1999), resulted stated that was
positive feeling states in relation to fast musical tempo music during aerobic exercise were found.
This present finding was similar to the finding report by Karageorghis et al. (2009), the motivational
music enhance feeling scale effect throughout the entire duration of task. This finding can be summarized that
when listening to the fast musical tempo, participant feeling during exercise was good. Exercises while listen to
fast musical gamelan tempo had made participants do not focused on feeling of fatigue and enjoy the exercise
more.
For instance, according to Karageorghis and Terry (1997) reported in study conducted by Elliott et al.
(2005), attending to musical stimuli may block the transmission of the internal sensation associate with physical
activity, for example, fatigue and effort sense. This research also reported study done by Rajeski (1985) that was
reported adopting an external focus can improve affect. This support the notion that although music not moderate
what participant feels when working at high intensity exercise, it can moderate how one feel it by Rajeski (1989)
in study conducted by Karageorghis et al. (2009).
Finding reported by Elliott et al. (2005) was measured feeling scale revealing that both music conditions
which is motivational and non motivational music provoked significantly more positive mood. Although

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motivational music elicited the greatest increase in affect. But contra finding by the present study, it shows slow
musical gamelan tempo impaired cycling performance when compare to no music. This maybe effect of slow
gamelan tempo which is ≤ 60 beat per minutes. When listened to slow musical gamelan tempo participant may
feel bored during cycling exercise.
According to Elliott et al. (2005) stated that, slow musical tempo can be played in the exercise
environment without provoking a negative response. Slow musical gamelan tempo might be effective when
listening during sport psychology for mental imagery purposes. This is because, commonly during imagery
session, relaxation music or slow musical tempo was played in order to make sure athletes are purely relaxed.
Distance pedalled (DP): The results of present study indicate that, when compare to slow musical
gamelan tempo and no music was significant different in distance pedalled during 20 minutes exercise. Base on
the median score, it shows that participants pedalled were father when listen to no music. It is maybe associated
with the RPE scale. When listened to fast musical gamelan tempo and slow musical gamelan tempo, participants
were preferred to increase their exercise intensity. When increase exercise intensity it may result decrease
distance pedalled.
For example when listened to fast musical gamelan tempo participants become more eager and
provoked to increase their effort as they choose to increase the exercise intensity, then the RPE scale reported
was slightly increase. Increase the exercise intensity likelihood may cause decrease distance pedalled. It should
be noted that from conversation with some of the participants, comments were passes regarding their experience
after listened to the different musical gamelan tempo, they was preferred to increase their exercise intensity
indirectly their RPE scale was increase when listen fast musical gamelan tempo. Finding for present study shows
that when gradient was increased that cause decrease distance pedalled. We recognize that inferences based upon
conversation with participants cannot be advanced as ‘scientific’ explanation; nevertheless, researcher should
perhaps consider the use of alternative assess distance pedalled related to exercise intensity.
Finding for present study was contradict with study reported by Elliott (2007) which their finding was
significant increase distance pedalled when listening to fast musical tempo and moderate musical tempo and
control condition. Finding by Elliott et al. (2005) also reported both motivational and oudeterous music elicited
significant increase in distance travelled during a 20 minutes cycling exercise. According Waterhouse et al.
(2010) their finding also reported there was increase the distance pedalled when listened to the music during
exercise.
Maybe this finding report does not emphasize the exercise intensity that may interrupt distance
pedalled. To see the effect of different musical tempo listened affect the exercise performance, then participants
were ask to pedalled at self selected exercise intensity in term of speed and gradient. So, it is important to take
consideration the speed and gradient pedalled because it can affect the distance pedalled.

Conclusion
Conclusion can be made, when listening to fast musical gamelan tempo, it caused participants able to
train at higher training heart rate zone for moderate intensity. Participant level of effort also was increases by
indicated using RPE scale. At the same time they feel good when doing exercise while listened to fast musical
tempo. There was a connection between RPE scale and distance pedalled found in the present study. When
listen to fast musical gamelan tempo, indirectly participants was motivated to increase their exercise intensity
that caused decrease distance pedalled.
Finding of the present study shows that participants enjoyed cycling session with music more compare
to without music. The music may have generated positive emotional states rather than acting purely as a disaster
(Nicola A Schie, 2008). They also reported fifty seven per cent of participants found that music can act as
stimulant which is cycling while listening to the music to be easier.

Acknowledgement
The researchers would like to express gratitude to the RMI (Research Management Institute) UiTM for
funding this study.

References
1. Attila Szabo, Lorna. J. Hoban. Psychological Effects of Fast- and Slow-Tempo Music Hayed during
Volleyball Training in a National League Team. Journal of Applied Sports Sciences. 2004;16(2), 39-48.
2. Birnbaum, L., Boone, T., Huschle, B. Cardiovascular Response to Music Tempo During Staedy-State
Exercise. Journal of Exercise Physiology Online. 2009; 12(1), 50-57.

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3. Elliott, D., Carr, S., Orme, D. The effect of motivational music on sub-maximal exercise. European Journal
of Sport Science. 2005; 5(2), 97-106.
4. Ghaderi, M., Rahimi, R., Ali Azarbayjani, M. The Effect of Motivational and Relaxation Music on
Aerobic Performance, Rating Perceived Exertion and Salivary Cortisol in Athelete Meals. South African
Journal for Research in Sport, Physical Education & Recreation (SAJR SPER). 2009; 31(2), 29-38.
5. Hardy, C. J., Rejeski, W. J. Not What, But How One Feels: The Measurement of Affect During Exercise.
Journal of Sport & Exercise Psychology. 1989; 11(3), 304-317.
6. Karageorghis, C. I., Mouzourides, D. A., Priest, D.-L., et al. Psychophysical and Ergogenic Effects of
Synchronous Music during Treadmill Walking. Journal of Sport & Exercise Psychology. 2009; 31(1), 18-
36.
7. Kelly, B., Kristal, B. Enhancing Sports Performance Through The Use Of Music. Journal of Exercise
Physiology Online. 2010; 13(2), 52-57.
8. Koç, H., Curtseıt, T. The Effects of Music on Athletic Performance. Ovidius University Annals, Series
Physical Education & Sport/Science, Movement & Health. 2010; 9(1), 44-47.
9. Mohammadzadeh, H., Tartibiyan, B., Ahmadi, A. The Effects of Music on Perceived Exertion Rate and
Performance of Trained and Individuals During Progressive Exercise. Facta Universitatis: Series Physical
Education & Sport. 2008; 6(1), 67-74.
10. Nicola A Schie, A. S., Pieter Backer & Geoff G Rogers. Effect of music on submaximal cycling. South
African Journal of Sports Medicin. 2008; 20.
11. Nicole M. Harmon, L. K., PhD. The Beat Goes On: The Effects Of Music On Exercise. IDEA Fitness
Journal. 2008.
12. Szabo, A., Small, A., Leigh, M. The effects of slow- and fast-rhythm classical music on progressive
cycling to voluntary physical exhaustion. Journal of Sports Medicine & Physical Fitness. 1999; 39(3), 220-
225.
13. Waterhouse, J., Hudson, P., Edwards, B. Effects of music tempo upon submaximal cycling performance.
Scandinavian Journal of Medicine & Science in Sports.2010; 20(4), 662-669.
14. Young, S. C., Sands, C. D., Jung, A. P. Effect of music in female college Soccer players during a maximal
treadmill test. International Journal of Fitness.2009; 5(2), 31-36.
15. Elliott, D. Music During Exercise: Does Tempo Influence Psychophysical Responses? Philica.com. 2007.

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Acute changes in blood pressure after physical

activities

Raja Yong S., Lee C.P., Moganan M., Misran M.H.I.

Company: Sport Research International Sdn. Bhd.

Abstract
Background
Statistic from Ministry of Health shows that only 25% of Malaysian people did the exercise and the rest
of 75% passive lifestyle. There have many consequences by not doing the exercise such as cardiovascular
disease, hypertension and diabetes. This study aimed to document the acute changes in blood pressure after
physical activities and the duration of significant blood pressure reduction.

Method
Eleven subjects of normal blood pressure people with mean age 27. The method of sampling is
randomized. All the subjects had undergone the 40 minutes of strengthening and aerobic exercise. The intensity
of aerobic is determined by calculation of maximum heart rate (MHR) and training heart rate (THR). The
aerobic session had breakdown into three phases which is warm up, aerobic and cool down. Moreover, the
strengthening exercises focus on ten major group muscles. Blood pressure reading taken pre and post exercise.

Result
The result shows that significant reduction in blood pressure pre and post exercise (p=0.001). The mean
value of blood pressure indicates sustain decrement on the systolic and diastolic pressure.

Conclusion
From the 11 subjects, there was a visible reduction in SBP and DBP, and exclusion of 5 subjects
demonstrate significant drop in SBP and DBP. The experiment also demonstrates the lower reading lasted for
period of 15 minutes.

Background
The effects of physical activities on clinical BP might be different in normotensive, hypotensive and
hypertensive individuals because cardiovascular haemodynamics are modified by hypertension. The effects of
aerobic and resistance exercise on Blood Pressure have different mechanical characteristics.The aerobics training
is characterized by large muscle groups contracting at mild to moderate intensities for a longer period. Heart
works harder to pump blood through the body more quickly more than the normal over extended period of time,
so the left ventricle of the heart enlarges and increase in stroke volume, thus cardiac output also increases. The
vasodilation of the artery happens increases the size of the lumen and thus reduces mean arterial pressure
(MAP).
For resistance exercise ; the spike of heart beat (ejection fraction) during resistance training, will
massage the vessel walls and nourishes the endothelial cells around the artery thus reducing the peripheral
resistance resulting a lower BP and reduce in mean arterial pressure (MAP).Two hormones epinephrine and
norepinephrine (the vasoconstrictors) on blood flow in the arteries also may effect in lowering BP. Aerobic
exercise can reduce the blood level of norepinephrine which limits the vasoconstriction of arterioles, allowing
for less peripheral resistance to BP. In addition, there is slight reduction in central nervous system (CNS) activity
that may help to mediate this decrease in BP. Endurance training decreases blood pressure through a reduction in
systemic vascular resistance, in which the sympathetic nervous system and the renin-angiotensin system appear
to be involved, and favourably affects concomitant cardiovascular risk factors. The few available data suggest
that resistance training can reduce blood pressure.

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Methodology
Subjects
A total of 11 subject participated in subjective assessment before proceed for the aerobic and
strengthening. Subjects were excluded if they (1) had a history of cardiovascular or renal diseases or diabetes;
(2) had electrocardiographic evidence of coronary heart disease or cardiac arrhythmia; (3) were hypertensive, as
defined by currently using any antihypertensive medication (4) severe degenerative disease.Physical activities in
this investigation are strength training and aerobic activities. Randomized samplings were used in subject
selection. Each subject undergoes 40 minutes of aerobic and strength training exercises.

Blood Pressure Measurement

After a 5-min rest in the sitting position, blood pressure was measured three times during two different
visits to the laboratory. On the occasion of each visit, blood pressure was measured by the same experienced
observer using a digital sphygmomanometer. Subjects were excluded if the average of the last two values
obtained during each visit for systolic and diastolic blood pressures was greater than 120 and 80 mmHg,
respectively.

Training Heart Rate

The intensity of aerobic is determined by calculation of maximum heart rate (MHR) and training heart
rate (THR). The aerobic session had breakdown into three phases which is warm up, aerobic and cool down.
Moreover, the strengthening exercises focus on ten major group muscles. Blood pressure reading taken pre and
post exercise.

Aerobic Training Strength Training

Intensity Dependant on activity level of Exertive at the last 3-

subjects: 5 reps
Inactive (55 – 60%)
Moderate (60 – 65%)
Active (65 – 70%)
Time 5 minutes (warm up) 3 sets of 10-15
20 minutes at THR repetitions
5 minutes (cold down) 30 seconds in
between sets
Type Treadmill/stationery bicycle Free weight (10
major muscles
groups)

The mean age of subjects is 27 years. The heart rate and blood pressure readings are measured and
taken during (1) pre workout and (2) immediate, 5 minutes, 10 minutes and 15 minutes post workout.

Results
Mean Value
No. of Subjects 5 MIN 10MIN 15MIN
SBP/DBP(HR) SBP/DBP(HR) SBP/DBP(HR)
11 (Total) 11.27/4.18(4.18) 14.27/1.36(6) 14.09/2.36(1.54)
6 (BP) 16/5(7.33) 17.83/6.16(7) 19.33/6.33(3)

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P Value
Parameters 11 (Total) 6 (BP)
HR 0.001 0.058
Diastolic 0.002 0.048
Systolic 0.041 0.041
P < 0.05 means significant changes

This study indicates significant changes in diastolic pressure and systolic pressure (p=0.048,p=0.041
p<0.05). The measurement taken for every 5 minutes, shows that blood pressure respond towards the physical
activity. Nevertheless, the magnitude and the time course of blood pressure changes after exercise are
inconsistent. In normotensives, the magnitude ranges from no change to falls as great as 30 mmHg.

Conclusion
The finding of this study was that structured and appropriate intensity of exercise give beneficial effect
of acute changes. The progression and load for exercise program should be planned accordingly in order to avoid
overtraining or overload. To prevent it, steady increase 5% of intensity of exercise should be implemented
(Budgett, 1990). The determination of duration rest interval depends on the intensity level of exercise. Most
studies dealing with post-exercise blood pressure responses have demonstrated that exercise reduces blood
pressure during the recovery period (Forjaz, Matsudaira, Rodrigues, Nunes, and Negrão, (1998). It has been
suggested that the development of hypertension is preceded by a prehypertensive state that may be manifested by
abnormal cardiovascular reactivity to environmental and behavioral challenges (Miyai, et al, 2002).

Reference
MIYAI, N. , ARITA, M., MIYASHITA, K., MORIOKA, I., SHIRAISHI, T. and NISHIO, I. (2002) Blood
Pressure Response to Heart Rate During Exercise Test and Risk of Future Hypertension, Journal of the
American Heart Association, pp:761 – 766.
FORJAZ C.L.M, MATSUDAIRA, Y., RODRIGUES, F.M., NUNES, N. and NEGRAO, C.E (1998) Post-
exercise changes in blood pressure, heart rate and rate pressure product at different exercise intensities in
normotensive humans. Braz J Med Biol Res, Vol 31(10), p:1247-1255.
BUDGETT, R., (1990). Overtraining Syndrome. Br J Sports Med. Vol 24, p: 231-236.

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Explain the income strategies of sport clubs from

view point of Tehran sport managers

Pirmohammadi M1, Omidzade Monfared M.1, Dehghani S.3

1-Department of physical education ,brujerdt Branch, Islamic Azad university,brujerd,Iran
3-Department of physical education ,Marvdasht Branch, Islamic Azad university,Marvdasht,Iran.
Corresponding author, Email: [email protected]

Introduction
Sport as a means to achieve objectives such as growth and optimal body modification, motor skills,
personality development, social progress and is targeted at the global level and the Olympics as a catalyst for
progress, understanding and mutual respect among nations is used There are many people all over the world.
Sports industry and its territory all around the world quickly subdued. (5) The economic aspects of the media
industry with virtually all groups of clothing, food and equipment are intertwined and can include direct impacts
on production, production services, sports tourism, exports of goods, a Places facilities advertising participation
In the stock market, attracting tourists and sponsors, create jobs, increase economic growth, health promotion
and ... Indirect effects include reduced treatment costs, increase efficiency and reduce manpower and enriching
leisure crime is affecting the national economy (5).

Methodology
The study was descriptive and causal - comparative (after the event) and the functional purpose of the
field survey data for this study were collected through a questionnaire. To study all the data of Sports and
Physical Education Department staff in Tehran marketing managers and directors of football federations,
weightlifting, wrestling, basketball and took the form of research, they go to work, they managed to collect 80
questions with multiple was. Due to the limited sample population includes all population is measured by means
of a questionnaire survey.Findings and conclusions based on the results of 75 exams between 10 and 20 years of
management experience, but only 25 /% of subjects older than 20 years of management experience 10 percent of
their degree and 25/86% of subjects undergraduate and graduate only 75/3% of them had a PhD. Of the subjects,
75/38 percent footballer, 5/22 vector wrestler 25%, 75/13% of basketball players and 25/71 per cent of
respondents were male and 75/28% of them were women. First, determine the normal distribution of data, the
Kolmogorov - Smirnov was used.

Results of the analysis using Friedman rank test, are given in Table 1-1
Sports site to attract supporters 23/57,26/4

Sponsorship of sporting events taking place 00000/1

12/4

Commercial use when sponsoring cultural exhibition tournament 45/3

Top of the credit institution Sport 38/3

The use of sponsors in sports broadcasting 93/2

Attracting foreign investment 86/2

Between the various elements of compensation Clubs of marketing (product), there is no significant difference.

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Table 1-2Dimensions of the priority Average Rating significant chi-square value

Sporting goods (balls, clothes, ...) 31/74 ,
85/4

To recruit famous players around the world 46/4

Granting exemptions, fiscal, trade, customs investors 35/4

Buy tickets for the team 16/4

Female viewers are sports fields, 93/3

Sales at the Stock Exchange Club 83/3

Buy clothes Players Championship after 43/2

Conclusion
Our findings indicated that income among various sports clubs, sponsors and advertising and marketing
is of primary importance are the next priorities.
Athletic directors from the perspective of the country - the most effective roles in advertising revenue
sports clubs, "the media advertising sales, ticket sales during competitions, advertising on sports clothing, selling
newspapers and magazines owned club, the use of the interviews and media publicity surrounding land, the right
to sell albums, calendars and books are the results of this study Rod Nuts uprising was born as advertising
around the pitch, or field dress, one of the main sources of income drinks to sports clubs or individuals (7) and 6
and divine concluded an obstacle to economic development industry football media player is (2) and Farley (8),
(4) in their research, such as that advertising One of the most important revenue channels and media in sports,
they are consistent (8)., but these findings with the results of Moharram Khalifa (7), Morgan due to different
countries as well as research and study of Vngrshshan Advertise categories inconsistent. (9) The results of
research findings by Ramazani, based on the economy and investment in sports that do not comply may no
agreement could be attributed to differences in the subject of study by society. (7).The most important and
effective role in marketing revenue sports clubs, sports products (balls, clothes, ...), to serve the rest of world
famous players, teams and competitions with the world further communication with the bus business While
Japan Karate Federation the marketing and sports marketing unit of the Federation, other than the above
production method, such as sports, will earn (6) Vale of the lack of agency, and human resources marketing
specialist <br> Sports and formulation of strategic plans and marketing operations in the football industry in
such problems are a major revenue sports clubs (4).

Resources
1- Atqya’, N., (1384). Interactivity Marketing, Sports Management, Sports Science Institute Journal of Research
in Physical Education and Sports Science Research, Ministry of Science and Technology. The first year,
the number one.
2- Ehsani, M., (1382). Sports Marketing Manager, Middle East Congress High H. (collection of articles). Tehran.
3- Lord, A., M., (1369). From production to consumption, marketing, publications December.
4 - bachchehaye, M., (1380). Propaganda in the media and its impact on consumer decision-making goods and
services, Proceedings of the First International Conference on the advertising industry.

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

5- Izadi, A., (1384). Describe factors Brjzb requirement sponsoring companies sponsoring professional football
in Iran, the Graduate School of Physical Education and Sport Sciences, Tarbiat Moallem University of
Tehran.
6 - Hassanzadeh, M., (1384). Sports marketing, publishing issue.
7 - Rahimi Boroujerdi, A., (1385). Privatization, Tehran University Press, first edition.
8 - Razavi, MH, (1383). Improve performance in sports privatization policy, the Journal, No. 23.
9 - Razavi, Mohammad Hossein, (1383). Privatization policy analysis with emphasis on the sport of athletics,
Ph.D. Dissertation in Sport Management, Faculty of Physical Education and Sport Sciences at Tehran
University.

© Medimond . Q926S7014 113

 Author Index Paththuwage R.G, 91
Pirmohammadi M, 111

Raja Yong S., 107

Ross V., 95
Adnan R., 95
Appukutty M., 95 Sasadai J., 65, 77
Sasaki S., 69
Balakrishnan B., 25 Shariff AH, 47
Buddhika W.H.S.W.R, 91 Shinohara H., 65, 77
Singh R., 51
Chee Keong Chen, 1 Sogabe A., 81
Ch’ng Ls., 3 Subasi F.., 55
Suga T., 73
Dehghani S., 111 Sulaiman N., 95

Fujii E., 65, 77 Takada S., 73

Takenouchi T., 87
George J., 3, 9 Taniura T., 73
Tatsumi T., 87
Hamid Msa, 3 Toh TH, 59
Hodgson L., 19 Tsutsui H., 73

Illias N.F., 95 Udyakumari A.D.M., 91

Inal H.S., 23 Urabe Y., 65, 77

Jaafar Z., 3 Weerasinghe W.C.S, 91

Wickramasinghe Y.M.N.M, 91
Kadoguchi T., 73 Wijayalath W.P.L.K, 91
Kinugawa S., 73
Kotoshiba S., 65 Yamamoto T., 65
Kubo Y., 69 Yokota T., 73

Lal P.R., 25
Lee C.P., 107

Maeda N., 65, 77

Mah LHK, 59
McKune A. J., 39
Misran M.H.I., 107
Moganan M., 107
Morita N., 73
Moriyama N., 65

Nagahama H., 69

Okita K., 73
Omidzade Monfared M., 111
Ong K., 43

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