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1.  Association between type of training and risk of asthma in elite athletes 
Thorax  1997;52(2):157-160.
BACKGROUND: Intensive endurance training has been associated with a high prevalence of symptoms compatible with asthma in elite athletes. It is not known, however, whether there is an association between the type of training for competitive events and the risk of asthma in highly trained athletes. METHODS: Two hundred and thirteen track and field athletes, mostly from Finnish national teams, and 124 controls of the same age completed a respiratory symptom questionnaire. Positive answers to physician diagnosed asthma were confirmed by personal interviews. The athletes were divided into two groups depending on whether they were speed and power athletes (n = 106) or long distance runners (n = 107). RESULTS: According to a logistic regression model the prevalence of physician diagnosed asthma was not associated with age, sex, or a family history of asthma. Long distance runners (OR 6.7; 95% CI 2.1 to 22.1) and speed and power athletes (OR 3.2; 95% CI 0.90 to 11.4) had a higher prevalence of physician diagnosed asthma than control subjects. Physician diagnosed asthma was found in 18 of 107 long distance runners (17%), in nine of 106 speed and power athletes (8%; p = 0.07 (chi 2 test)), and in four of 124 controls (3%; p < 0.0004 (chi 2 test for trend)). CONCLUSIONS: The prevalence of physician diagnosed asthma is high in elite athletes and an association with the competitive event is suggested with long distance runners having a greater risk of developing asthma than speed and power athletes. This may be due to prolonged hyperventilation and increased exposure to inhalant allergens and irritants during endurance training and competition. 

PMCID: PMC1758476  PMID: 9059477
2.  Seasonal Strength Performance and Its Relationship with Training Load on Elite Runners 
The aim of this study was to analyze the time-course of force production of elite middle and long-distance runners throughout an entire season and at the end of the off-season, as well as its relationships with training load and hormonal responses. Training load was recorded daily throughout an entire season by measuring and evaluating the session distance (km), training zone and session-RPE in a group of 15 elite middle and long-distance runners (12 men, 3 women; age = 26.3 ± 5.1yrs, BMI = 19.7 ± 1.1). Also, basal salivary-free cortisol levels were measured weekly, and 50-metre sprints, mean propulsive velocity (MPV), mean propulsive power (MPP), repetition maximum (RM) and peak rate of force development (RFD) of half-squats were measured 4 times during the season, and once more after the off-season break. There were no significant variations in force production during the season or after the off-season break, except for the RFD (-30.2%, p = 0.005) values, which changed significantly from the beginning to the end of the season. Significant correlations were found between session-RPE and MPV (r = -0.650, p = 0.004), MPP (r = -0.602, p = 0.009), RM (r = -0.650, p = 0.004), and the 50-metre sprint (r = 0.560, p = 0.015). Meanwhile, salivary-free cortisol correlated significantly with the 50-metre sprint (r = 0.737, p < 0.001) and the RM ( r = -0.514, p = 0.025). Finally, the training zone correlated with the 50-metre sprint (r = -0.463, p = 0.041). Session-RPE, training zone and salivary-free cortisol levels are related to force production in elite middle and long-distance runners. Monitoring these variables could be a useful tool in controlling the training programs of elite athletes.
Key pointsSession-RPE, training zone and salivary free cortisol levels correlate significantly with strength-related variables in middle and long-distance elite runners.A month of active rest during the off-season break is enough to prevent decreases in force production of such athletes.Monitoring training loads through session-RPE is a suitable and simple method for controlling the training process in elite middle and long-distance runners.
PMCID: PMC4306788  PMID: 25729283
Endurance; exercise; testing; physiology
3.  Attitudes and doping: a structural equation analysis of the relationship between athletes' attitudes, sport orientation and doping behaviour 
For effective deterrence methods, individual, systemic and situational factors that make an athlete or athlete group more susceptible to doping than others should be fully investigated. Traditional behavioural models assume that the behaviour in question is the ultimate end. However, growing evidence suggests that in doping situations, the doping behaviour is not the end but a means to an end, which is gaining competitive advantage. Therefore, models of doping should include and anti-doping policies should consider attitudes or orientations toward the specific target end, in addition to the attitude toward the 'tool' itself.
The aim of this study was to empirically test doping related dispositions and attitudes of competitive athletes with the view of informing anti-doping policy developments and deterrence methods. To this end, the paper focused on the individual element of the drug availability – athlete's personality – situation triangle.
Data were collected by questionnaires containing a battery of psychological tests among competitive US male college athletes (n = 199). Outcome measures included sport orientation (win and goal orientation and competitiveness), doping attitude, beliefs and self-reported past or current use of doping. A structural equation model was developed based on the strength of relationships between these outcome measures.
Whilst the doping model showed satisfactory fit, the results suggested that athletes' win and goal orientation and competitiveness do not play a statistically significant role in doping behaviour, but win orientation has an effect on doping attitude. The SEM analysis provided empirical evidence that sport orientation and doping behaviour is not directly related.
The considerable proportion of doping behaviour unexplained by the model suggests that other factors play an influential role in athletes' decisions regarding prohibited methods. Future research, followed by policy development, should incorporate these factors to capture the complexity of the doping phenomenon and to identify points for effective anti-doping interventions. Sport governing bodies and anti-doping organisations need to recognise that using performance enhancements may be more of a rational, outcome optimizing behaviour than deviance and consider offering acceptable alternative performance-enhancing methods to doping.
PMCID: PMC2217289  PMID: 17996097
4.  Mood, mileage and the menstrual cycle. 
Forty women took part in a study to determine the effects of high-intensity training and the menstrual cycle on mood states. Half of the sample were competitive distance runners following a training load of between 50 km and 130 km running per week. Seven athletes were amenorrhoeic and 13 either eumenorrhoeic or oligomenorrhoeic. The remaining 20 subjects were inactive women who menstruated regularly. The mean age of all 40 subjects was 29 years. Each subject completed two identical Profile of Mood States (POMS) questionnaires. The 33 menstruating subjects completed both a premenstrual and a midcycle form and the amenorrhoeic athletes completed the questionnaires at a 3-week interval, which acted as a control for the potential effects of premenstrual syndrome (PMS) among the menstruating females. Results showed highly significant differences in mood profiles among amenorrhoeic athletes, non-amenorrhoeic athletes and inactive women. The greatest difference was between premenstrual and midcycle measures for the inactive group. PMS appears to cause marked negative mood swings among menstruating women which the POMS inventory is sensitive in detecting. While the lower-intensity-training runners appeared to benefit psychologically from a training distance of approximately 50 km week-1, high-intensity training had an adverse effect on mood.
PMCID: PMC1478953  PMID: 1422649
5.  Echocardiographic Parameters in Athletes of Different Sports 
Competitive athletics is often associated with moderate left ventricular (LV) hypertrophy, and it has been hypothesized that training mode and type of exercise modulates long-term cardiac adaptation. The purpose of the study was to compare cardiac structure and function among athletes of various sports and sedentary controls. Standard transthoracic two-dimensional M-mode and Doppler echocardiography was performed at rest in Caucasian male canoe/kayak paddlers (n = 9), long distance runners (LDR, n = 18), middle distance runners (MDR, n = 17), basketball players (BP, n = 31), road cyclists (n = 8), swimmers (n = 10), strength/power athletes (n = 9) of similar age (range, 15 to 31 yrs), training experience (4 to 9 years), and age-matched healthy male sedentary controls (n = 15). Absolute interventricular septum (IVS) thickness and LV wall thickness, but not LV diameter, were greater in athletes than sedentary controls. Left ventricular mass of all athletes but relative wall thickness of only BP, swimmers, cyclists, and strength/power athletes were higher as compared with controls (p < 0.05). Among athletes, smaller IVS thickness was observed in MDR than BP, cyclists, swimmers or strength/power athletes, while LDR had higher body size-adjusted LV diameter as compared to BP, cyclists and strength/power athletes. In conclusion, relative LV diameter was increased in long distance runners as compared with basketball players, cyclists, and strength/power athletes. Basketball, road cycling, strength/power, and swimming training were associated with increased LV concentricity as compared with paddling or distance running.
Key pointsThe type of cardiac hypertrophy seems to be only moderately exercise-specific.Long-distance runners develop larger left ventricular dilation as compared with basketball players, cyclists, and strength/power athletes.Myocardial wall thickening is triggered by different sporting activities that involve large muscle groups.
PMCID: PMC3763341  PMID: 24150148
Myocardial hypertrophy; left ventricle; echocardiography; athlete
6.  Grip strength measurements at two different wrist extension positions in chronic lateral epicondylitis-comparison of involved vs. uninvolved side in athletes and non athletes: a case-control study 
Lateral epicondylitis is a common sports injury of the elbow caused due to altered muscle activation during repetitive wrist extension in many athletic and non-athletic endeavours. The amount of muscle activity and timing of contraction eventually is directly dependent upon joint position during the activity. The purpose of our study was to compare the grip strength in athletes with lateral epicondylalgia in two different wrist extension positions and compare them between involved and uninvolved sides of athletes and non-athletes.
An assessor-blinded case-control study of eight athletes and twenty-two non-athletes was done. The grip strength was measured using JAMAR® hand dynamometer in kilograms-force at 15 degrees (slightly extended) and 35 degrees (moderately extended) wrist extension positions (maintained by wrist splints) on both involved and uninvolved sides of athletes and non-athletes with unilateral lateral epicondylitis of atleast 3 months duration. Their pain was to be elicited with local tenderness and two of three tests being positive- Cozen's, Mill's manoeuvre, resisted middle finger extension tests. For comparisons of grip strength, Wilcoxon signed rank test was used for within-group comparison (between 15 and 35 degrees wrist extension positions) and Mann-Whitney U test was used for between-group (athletes vs. non-athletes) comparisons at 95% confidence interval and were done using SPSS 11.5 for Windows.
Statistically significant greater grip strength was found in 15 degrees (27.75 ± 4.2 kgms in athletes; 16.45 ± 4.2 kgms in non-athletes) wrist extension than at 35 degrees (25.25 ± 3.53 kgm in athletes and 14.18 ± 3.53 kgm in non-athletes). The athletes had greater grip strength than non-athletes in each of test positions (11.3 kgm at 15 degrees and 11.07 kgm at 35 degrees) measured. There was also a significant difference between involved and uninvolved sides' grip strength at both wrist positions (4.44 ± .95 kgm at 15 degrees and 4.44 ± .86 kgm in 35 degrees) which was significant (p < .05) only in non-athletes.
The grip strength was greater in 15 degrees wrist extension position and this position could then be used in athletes with lateral epicondylalgia for grip strength assessment and designing wrist splint in this population.
PMCID: PMC2944326  PMID: 20822520
7.  AQUA© as predictor of allergy in elite marathon runners 
The prevalence of allergy in athletes is increasing, and its risk varies across sports. The risk is dependent mainly on the ventilation rate and environmental factors; however, the prevalence of allergy in elite runners remains unknown. Therefore, the aim of this study was to screen allergy symptoms in elite marathon runners by using a validated questionnaire for screening allergy in athletes.
Two hundred and one elite marathoners, who participated in the most competitive Brazilian marathons and half-marathons during 2011, were invited to complete a validated self-report Allergy Questionnaire for Athletes (AQUA©), with additional questions pertaining to training history, such as running experience, running distance per week and their best race time in marathon or half-marathon events.
Sixty percent of the assessed athletes reported allergy symptoms as defined by a positive AQUA outcome (score [greater than or equal to] 5). No significant differences (p > 0.05) between groups (AQUA + and AQUA-) were observed for gender, age, running experience, weekly training volume and best performance time in the half-marathon and marathon. The most frequently reported symptoms were related to the respiratory tract and physical effort.
This study demonstrates that AQUA© can be used to predict allergy in elite marathon runners. In addition, these athletes have a higher prevalence of allergy symptoms to elite athletes from other sports.
PMCID: PMC3983857  PMID: 24708728
8.  Asthma and other pulmonary diseases in former elite athletes. 
Thorax  1996;51(3):288-292.
BACKGROUND: The prevalence of asthma is rising and there are recent reports of increasing asthma rates among top level skiers and runners in the Nordic countries. METHODS: The lifetime occurrence of pulmonary diseases (asthma, chronic bronchitis, emphysema) and current bronchitis symptoms was compared in former elite male athletes (n = 1282) who represented Finland between 1920 and 1965 at least once in international competitions and controls (n = 777) who, at the age of 20, were classified as healthy and who responded to a questionnaire in 1985. The presence of disease and symptoms was identified from the questionnaire and, in the case of asthma, also from a nationwide reimbursable medication register. The death certificates of the subjects of our original cohort who died between 1936 and 1985 were also investigated to determine the cause of death. RESULTS: The occurrence of the pulmonary diseases was associated with age, smoking habits, occupational group, and a history of exposure to chemicals. After adjusting for these variables, athletes who participated in mixed sports (odds ratio (OR) 0.46, 95% confidence interval (CI) 0.23 to 0.92) and power sports (OR 0.43, 95% CI 0.21 to 0.87) had lower odds ratios for emphysema, and endurance sports athletes had a lower odds ratio for the presence of at least one pulmonary disease (OR 0.53, 95% CI 0.28 to 0.98) when compared with controls. Athletes also tended to have fewer reimbursable medications for asthma and fewer current symptoms for chronic bronchitis. Between 1936 and 1985 two controls but none of the athletes died of asthma. CONCLUSIONS: The lifetime occurrence of asthma or other pulmonary diseases is not increased in former elite athletes, and exercise alone, even in a cold environment, did not appear to increase the prevalence of asthma, at least up to the mid 1980s.
PMCID: PMC1090641  PMID: 8779133
9.  Effect of long haul travel on maximal sprint performance and diurnal variations in elite skeleton athletes 
To quantify the impact of eastward long haul travel on diurnal variations in cortisol, psychological sensations and daily measurements of physical performance.
Five elite Australian skeleton athletes undertook a long haul eastward flight from Australia to Canada (LHtravel), while seven elite Canadian skeleton athletes did not travel (NOtravel). Salivary cortisol was measured on awakening, 60 min and 120 min after awakening. Psychological sensations were measured with a questionnaire, and maximal 30 m sprints were performed once a day between 09:30 and 11:00 h local time.
Compared with baseline, average (SD) resting salivary cortisol decreased by 67% immediately after long haul travel (23.43 (5.71) nMol/l) (mean±90% confidence interval) in the LHtravel group (p = 0.03), while no changes were found in the NOtravel group (p = 0.74). There were no significant differences in 30 m sprint time between baseline and post‐flight tests in the LHtravel group (p>0.05). The LHtravel group perceived themselves as “jet lagged” for up to 2 days after the flight (p = 0.01 for both midday lunch and evening dinner).
Despite a distinct phase change in salivary cortisol rhythmicity and the athletes perceiving themselves as “jet lagged”, minimal disturbances in “one‐off” maximal sprinting ability between 09:30 and 11:00 h local time were seen in a group of elite skeleton athletes after long haul eastward travel from Australia to Canada.
PMCID: PMC2465388  PMID: 17473002
circadian dysrhythmia; time zones; elite athletes; salivary cortisol
10.  Anthropometric and training variables related to 10km running performance. 
Sixty male distance athletes were divided into three equal groups according to their personal best time for the 10km run. The runners were measured anthropometrically and each runner completed a detailed questionnaire on his athletic status, training programme and performance. The runners in this study had similar anthropometric and training profiles to other distance runners of a similar standard. The most able runners were shorter and lighter than those in the other two groups and significantly smaller skinfold values (P less than 0.05). There were no significant differences between the groups for either bone widths or circumferences but the elite and good runners had significantly higher ponderal indices (P less than 0.05) than the average runners, indicating that they are more linear. Elite and good runners were also less endomorphic but more ectomorphic than the average runners. The elite runners trained more often, ran more miles per week and had been running longer (P less than 0.05) than good or average runners. A multiple regression and discriminant function analysis indicated that linearity, total skinfold, the type and frequency of training and the number of years running were the best predictors of running performance and success at the 10km distance.
PMCID: PMC1478338  PMID: 3814989
11.  Use of Evidence-Based Practice Among Athletic Training Educators, Clinicians, and Students, Part 2: Attitudes, Beliefs, Accessibility, and Barriers 
Journal of Athletic Training  2013;48(3):405-415.
Successful implementation of evidence-based practice (EBP) within athletic training is contingent upon understanding the attitudes and beliefs and perceived barriers toward EBP as well as the accessibility to EBP resources of athletic training educators, clinicians, and students.
To assess the attitudes, beliefs, and perceived barriers toward EBP and accessibility to EBP resources among athletic training educators, clinicians, and students.
Cross-sectional study.
Online survey instrument.
Patients or Other Participants:
A total of 1209 athletic trainers participated: professional athletic training education program directors (n = 132), clinical preceptors (n = 266), clinicians (n = 716), postprofessional athletic training educators (n = 24) and postprofessional students (n = 71).
Main Outcome Measure(s):
Likert-scale items (1 = strongly disagree, 4 = strongly agree) assessed attitudes and beliefs and perceived barriers, whereas multipart questions assessed accessibility to resources. Kruskal-Wallis H tests (P ≤ .05) and Mann-Whitney U tests with a Bonferroni adjustment (P ≤ .01) were used to determine differences among groups.
Athletic trainers agreed (3.27 ± 0.39 out of 4.0) that EBP has various benefits to clinical practice and disagreed (2.23 ± 0.42 out of 4.0) that negative perceptions are associated with EBP. Benefits to practice scores (P = .002) and negative perception scores (P < .001) differed among groups. With respect to perceived barriers, athletic trainers disagreed that personal skills and attributes (2.29 ± 0.52 out of 4.0) as well as support and accessibility to resources (2.40 ± 0.40 out of 4.0) were barriers to EBP implementation. Differences were found among groups for personal skills and attributes scores (P < .001) and support and accessibility to resources scores (P < .001). Time (76.6%) and availability of EBP mentors (69.6%) were the 2 most prevalent barriers reported. Of the resources assessed, participants were most unfamiliar with clinical prediction rules (37.6%) and Cochrane databases (52.5%); direct access to these 2 resources varied among participants.
Athletic trainers had positive attitudes toward the implementation of EBP within didactic education and clinical practice. However, accessibility and resource use remained low for some EBP-related resources. Although the perceived barriers to implementation are minimal, effective integration of EBP within athletic training will present challenges until these barriers dissolve.
PMCID: PMC3655754  PMID: 23675800
athletic training education; evidence-based medicine; survey research
12.  Low back pain status in elite and semi-elite Australian football codes: a cross-sectional survey of football (soccer), Australian rules, rugby league, rugby union and non-athletic controls 
Our understanding of the effects of football code participation on low back pain (LBP) is limited. It is unclear whether LBP is more prevalent in athletic populations or differs between levels of competition. Thus it was the aim of this study to document and compare the prevalence, intensity, quality and frequency of LBP between elite and semi-elite male Australian football code participants and a non-athletic group.
A cross-sectional survey of elite and semi-elite male Australian football code participants and a non-athletic group was performed. Participants completed a self-reported questionnaire incorporating the Quadruple Visual Analogue Scale (QVAS) and McGill Pain Questionnaire (short form) (MPQ-SF), along with additional questions adapted from an Australian epidemiological study. Respondents were 271 elite players (mean age 23.3, range 17–39), 360 semi-elite players (mean age 23.8, range 16–46) and 148 non-athletic controls (mean age 23.9, range 18–39).
Groups were matched for age (p = 0.42) and experienced the same age of first onset LBP (p = 0.40). A significant linear increase in LBP from the non-athletic group, to the semi-elite and elite groups for the QVAS and the MPQ-SF was evident (p < 0.001). Elite subjects were more likely to experience more frequent (daily or weekly OR 1.77, 95% CI 1.29–2.42) and severe LBP (discomforting and greater OR 1.75, 95% CI 1.29–2.38).
Foolers in Australia have significantly more severe and frequent LBP than a non-athletic group and this escalates with level of competition.
PMCID: PMC2674424  PMID: 19371446
13.  Use of dietary supplements in Olympic athletes is decreasing: a follow-up study between 2002 and 2009 
The aim of this study was to assess the frequency of use of dietary supplements (DS) among large sample of elite Finnish athletes and to describe possible changes in dietary supplement use between the years 2002 and 2009.
A prospective follow-up study was conducted on Olympic athletes. The first survey was conducted on Olympic athletes in 2002 (N = 446) and the follow-up study was conducted between May 2008 and June 2009 (N = 372).
In 2002, a total of 81% of the athletes used dietary supplements (a mean of 3.37 ± 3.06 DS per user) and in 2009, a total of 73% of the athletes (a mean of 2.60 ± 2.69 per DS user) used them. After adjusting for age-, sex- and sport type, the OR (95% confidence interval, CI) for use of any dietary supplement was significantly less in 2009 as compared with 2002 results (OR, 0.62; 95% CI, 0.43-0.90). Decrease in DS use was observed in all supplement subgroups (vitamins, minerals, nutritional supplements). Athletes in speed and power events and endurance events reported use of any dietary supplement significantly more often than team sport athletes both in 2002 and 2009. In year 2009, the frequency of all dietary supplement use increased when athlete's age increased and the increase was significant in older age groups: of the athletes under 21 years 63%, 21-24 years 83% and over 24 years 90% consumed nutritional supplements.
Based in our study, there seems to be a lowering trend of dietary supplement use among elite Finnish athletes although differences between sport subgroups and age groups are considerable.
PMCID: PMC3042913  PMID: 21294857
14.  Participation in leanness sports but not training volume is associated with menstrual dysfunction: a national survey of 1276 elite athletes and controls 
Objective: To examine the prevalence of menstrual dysfunction in the total population of Norwegian elite female athletes and national representative controls in the same age group.
Methods: A detailed questionnaire that included questions on training and/or physical activity patterns, menstrual, dietary, and weight history, oral contraceptive use, and eating disorder inventory subtests was administered to all elite female athletes representing the country at the junior or senior level (aged 13–39 years, n = 938) and national representative controls in the same age group (n = 900). After exclusion, a total of 669 athletes (88.3%) and 607 controls (70.2%) completed the questionnaire satisfactorily.
Results: Age at menarche was significantly (p<0.001) later in athletes (13.4 (1.4) years) than in controls (13.0 (1.3) years), and differed among sport groups. A higher percentage of athletes (7.3%) than controls (2.0%) reported a history of primary amenorrhoea (p<0.001). A similar percentage of athletes (16.5%) and controls (15.2%) reported present menstrual dysfunction, but a higher percentage of athletes competing in leanness sports reported present menstrual dysfunction (24.8%) than athletes competing in non-leanness sports (13.1%) (p<0.01) and controls (p<0.05).
Conclusions: These novel data include virtually all eligible elite athletes, and thus substantially extend previous studies. Age at menarche occurred later and the prevalence of primary amenorrhoea was higher in elite athletes than in controls. A higher percentage of athletes competing in sports that emphasise thinness and/or a specific weight reported present menstrual dysfunction than athletes competing in sports focusing less on such factors and controls. On the basis of a comparison with a previous study, the prevalence of menstrual dysfunction was lower in 2003 than in 1993.
PMCID: PMC1725151  PMID: 15728691
15.  Nutrient Intakes of Men and Women Collegiate Athletes with Disordered Eating 
The objective of this study was to assess the macro- and micronutrient intakes of men and women collegiate athletes with disordered eating behaviors and to compare the nutrient intakes of athletes with restrictive- versus binge-eating behaviors. National Collegiate Athletic Association (NCAA) Division I University athletes (n = 232) were administered an anonymous, written questionnaire to compare nutrient intakes, desired weight change, and weight control behaviors in athletes with restrictive- (R) and binge- (B) eating behaviors to those in asymptomatic (A) athletes. T-tests, χ2 statistic, and ANOVA were used to test for differences among disordered eating groups within genders (p < 0.05). Data are means ± standard error of the mean. Among men athletes, those with disordered eating consumed a smaller percentage of energy from carbohydrate compared to controls (R = 49.7 ± 1.5; B = 48.7 ± 2.3; A = 53.4 ± 0.7%). Among female athletes, those with disordered eating wanted to lose a greater percentage of their current body weight than did asymptomatic athletes (B = -6.1 ± 1.4; R = -6.7 ± 1.1; A = -3.7 ± 0.4%). Women who were classified with binge eating consumed significantly more alcohol than did controls (B = 6.8 ± 1.3; A = 3.9 ± 0.4 g alcohol per day). Athletes with disordered eating were more likely to report restricting their intake of carbohydrate and fat and using supplements to control their weight than asymptomatic athletes. Disordered eating was not associated with greater frequencies of inadequate micronutrient intake in either gender. Athletes with disordered eating may be at significantly greater risk for nutritional inadequacies than athletes who are asymptomatic due to macronutrient restriction and greater alcohol consumption.
Key PointsAthletes with disordered eating were more likely to report restricting their intake of carbohydrate and fat and using supplements to control their weight than asymptomatic athletesAmong female athletes, those with disordered eating wanted to lose a greater percentage of their current body weight than did asymptomatic athletesDisordered eating was not associated with greater frequencies of inadequate micronutrient intake in either genderAthletes with disordered eating may be at significantly greater risk for nutritional inadequacies than athletes who are asymptomatic due to macronutrient restriction and greater alcohol consumption.
PMCID: PMC3887328  PMID: 24453529
Eating disorder; Female Athlete Triad
16.  Is there a danger for myopia in anti-doping education? Comparative analysis of substance use and misuse in Olympic racket sports calls for a broader approach 
Racket sports are typically not associated with doping. Despite the common characteristics of being non-contact and mostly individual, racket sports differ in their physiological demands, which might be reflected in substance use and misuse (SUM). The aim of this study was to investigate SUM among Slovenian Olympic racket sport players in the context of educational, sociodemographic and sport-specific factors.
Elite athletes (N = 187; mean age = 22 ± 2.3; 64% male) representing one of the three racket sports, table tennis, badminton, and tennis, completed a paper-and-pencil questionnaire on substance use habits. Athletes in this sample had participated in at least one of the two most recent competitions at the highest national level and had no significant difference in competitive achievement or status within their sport.
A significant proportion of athletes (46% for both sexes) reported using nutritional supplements. Between 10% and 24% of the studied males would use doping if the practice would help them achieve better results in competition and if it had no negative health consequences; a further 5% to 10% indicated potential doping behaviour regardless of potential health hazards. Females were generally less oriented toward SUM than their male counterparts with no significant differences between sports, except for badminton players. Substances that have no direct effect on sport performance (if timed carefully to avoid detrimental effects) are more commonly consumed (20% binge drink at least once a week and 18% report using opioids), whereas athletes avoid substances that can impair and threaten athletic achievement by decreasing physical capacities (e.g. cigarettes), violating anti-doping codes or potentially transgressing substance control laws (e.g. opiates and cannabinoids). Regarding doping issues, athletes' trust in their coaches and physicians is low.
SUM in sports spreads beyond doping-prone sports and drugs that enhance athletic performance. Current anti-doping education, focusing exclusively on rules and fair play, creates an increasingly widening gap between sports and the athletes' lives outside of sports. To avoid myopia, anti-doping programmes should adopt a holistic approach to prevent substance use in sports for the sake of the athletes' health as much as for the integrity of sports.
PMCID: PMC3204239  PMID: 21988896
racket sport; anti-doping; drug; athlete; drinking; supplements
During the 2013‐14 school year, over 763,000 female athletes participated in interscholastic running sports in the United States. Recent studies have indicated associations between the female athlete triad (Triad) and stress fracture or other musculoskeletal injuries in elite or collegiate female running populations. Little is known about these relationships in an adolescent interscholastic running population. The purpose of this study was to determine the associations between Triad and risk of lower extremity musculoskeletal injury among adolescent runners.
Eighty‐nine female athletes competing in interscholastic cross‐country and track in southern California were followed, prospectively. The runners were monitored throughout their respective sport season for lower extremity musculoskeletal injuries. Data collected included daily injury reports, Eating Disorder Examination Questionnaire (EDE‐Q) that assessed disordered eating attitudes/behaviors, a questionnaire on menstrual history and demographic characteristics, a dual‐energy x‐ray absorptiometry scan that measured whole‐body bone mineral density (BMD) and body composition (lean tissue and fat mass), and anthropometric measurements.
Thirty‐eight runners (42.7%) incurred at least one lower extremity musculoskeletal injury. In the BMD Z‐score ≤ ‐1 standard deviation (SD) adjusted model, low BMD relative to age (BMD Z‐score of ≤ ‐1SD) was significantly associated (Odds Ratio [OR]=4.6, 95% confidence interval [CI]: 1.5‐13.3) with an increased occurrence of musculoskeletal injury during the interscholastic sport season. In the BMD Z‐score ≤ ‐2 SDs adjusted model, a history of oligo/amenorrhea was significantly associated (OR=4.1, 95% CI: 1.2‐13.5) with increased musculoskeletal injury occurrence.
Oligo/amenorrhea and low BMD were associated with musculoskeletal injuries among the female interscholastic cross‐country and track runners.
Clinical Relevance:
Regular, close monitoring of adolescent female runners during seasonal and off‐season training may be warranted, so that potential problems can be recognized and addressed promptly in order to minimize the risk of running injury.
Level Of Evidence:
PMCID: PMC4275199  PMID: 25540710
Adolescent runners; bone mineral density; disordered eating; females; menstrual dysfunction; musculoskeletal injuries
18.  Anti-doping education and dietary supplementation practice in Korean elite university athletes 
Nutrition Research and Practice  2011;5(4):349-356.
This study was conducted to investigate relationships and gender differences in dietary supplement (DS) and oriental supplement (OS) prevalence as well as anti-doping awareness during training and the game period. Korea National Sport University athletes (343 male and 136 female) participated in this study and completed DS and OS practice and anti-doping awareness questionnaires. Forty-six percent of athletes used DS during the training period, and there was significantly higher DS use in females (53%) compared to males (43%) (P < 0.05). Twenty-eight percent of athletes used OS, and there was significantly higher OS use in females (35%) than males (26%) (P < 0.05) during the training period. The primary reason of DS use was to supply energy both in males (36%) and females (28%). The main reason for male athletes' OS use was to supply energy (41%). Meanwhile, the reasons for female athletes' OS use were to supply energy (23%), to maintain health (19%), and to improve recovery ability (20%), which showed a significant gender difference (P < 0.05). Athletes rated their perceived degree of satisfaction, perceived importance, and beliefs in efficacy of DS and OS use all over 50% during the training period, and no gender differences were detected. In a comparison between athletes educated about anti-doping (at least more than one time) and non-received athletes, DS and OS use during the training period was 2.30 (1.47-3.60) and 1.71 (1.03-2.82), respectively. DS and OS use immediately before the game period was 2.38 (1.50-3.80) and 3.99 (1.20-13.28), respectively. Elite athletes' anti-doping education was highly related to increased DS use during the training period and immediately before the game. Although elite athletes use various DS and OS during the training period and before the game period, doping education for elite athletes is related with DS and OS use during the training period and before the game.
PMCID: PMC3180686  PMID: 21994530
Dietary supplementation; anti-doping education; elite athletes
19.  "Abnormal" illness behaviour in chronic fatigue syndrome and multiple sclerosis. 
BMJ : British Medical Journal  1995;311(6996):15-18.
OBJECTIVE--To investigate the presence of abnormal illness behaviour in patients with a diagnosis of chronic fatigue syndrome. DESIGN--A cross sectional descriptive study using the illness behaviour questionnaire to compare illness behaviour scores and illness behaviour profiles of patients with chronic fatigue syndrome and patients with multiple sclerosis. SETTING--A multidisciplinary fatigue clinic and a teaching hospital neurology outpatient clinic. SUBJECTS--98 patients satisfying the Oxford criteria for chronic fatigue syndrome and 78 patients with a diagnosis of multiple sclerosis. MAIN OUTCOME MEASURE--Responses to the 62 item illness behaviour questionnaire. RESULTS--90 (92%) patients in the chronic fatigue syndrome group and 70 (90%) in the multiple sclerosis group completed the illness behaviour questionnaire. Both groups had significantly high scores on the general hypochondriasis and disease conviction subscales and significantly low scores on the psychological versus somatic concern subscale, as measured in relation to normative data. There were, however, no significant differences in the subscale scores between the two groups and the two groups had identical illness behaviour profiles. CONCLUSION--Scores on the illness behaviour questionnaire cannot be taken as evidence that chronic fatigue syndrome is a variety of abnormal illness behaviour, because the same profile occurs in multiple sclerosis. Neither can they be taken as evidence that chronic fatigue and multiple sclerosis share an aetiology. More needs to be known about the origins of illness beliefs in chronic fatigue syndrome, especially as they are important in determining outcome.
PMCID: PMC2550080  PMID: 7613314
20.  Factors associated with hip joint rotation in former elite athletes 
Objectives—To study factors associated with passive hip rotation range of motion (ROM) in former elite male athletes.
Methods—Athletes were interviewed about hip pain, disability, lifetime occupational loading, and athletic training. The passive hip rotation was measured with a Myrin inclinometer in 117 former elite male long distance runners, soccer players, weight lifters, and shooters aged 45–68 years. Magnetic resonance imaging was used to detect hip osteoarthritis.
Results—There were no differences in passive hip rotation ROM between the four athlete groups nor between diverging lifetime loading patterns associated with occupational or athletic activities. Among the subjects without hip osteoarthritis, hip pain, and hip disability according to a stepwise linear regression analysis, the only factor that was associated with the passive hip rotation ROM was body mass index (BMI), explaining about 21% of its variation. Subjects with high BMI had lower passive hip rotation ROM than those with low BMI. There was no right-left difference in the mean passive hip rotation ROM in subjects either with or without hip osteoarthritis as determined by magnetic resonance imaging. Nevertheless, hip rotation ROM was clearly reduced in a few hips with severe caput deformity.
Conclusions—Long term loading appears to have no association with passive hip rotation ROM. On the other hand, the hip rotation value was lower in subjects with high BMI than in those with low BMI. A clear right-left difference in hip rotation was found only in those subjects who, according to our magnetic resonance imaging criteria, had severe hip osteoarthritis. These findings should be taken into account when hip rotation ROM is used in the clinical assessment of hip joints.
Key Words: hip joint rotation; range of motion; osteoarthritis; athletic training; body mass index
PMCID: PMC1724139  PMID: 10690450
21.  Electrocardiographic changes in 1000 highly trained junior elite athletes 
OBJECTIVES: To evaluate the spectrum of electrocardiographic (ECG) changes in 1000 junior (18 or under) elite athletes. METHODS: A total of 1000 (73% male) junior elite athletes (mean (SD) age 15.7 (1.4) years (range 14-18); mean (SD) body surface area 1.73 (0.17) m2 (range 1.09-2.25)) and 300 non-athletic controls matched for gender, age, and body surface area had a 12 lead ECG examination. RESULTS: Athletes had a significantly higher prevalence of sinus bradycardia (80% v 19%; p<0.0001) and sinus arrhythmia (52% v 9%; p<0.0001) than non-athletes. The PR interval, QRS, and QT duration were more prolonged in athletes than non-athletes (153 (20) v 140 (18) milliseconds (p<0.0001), 92 (12) v 89 (7) milliseconds (p<0.0001), and 391 (27) v 379 (29) milliseconds (p = 0.002) respectively). The Sokolow voltage criterion for left ventricular hypertrophy (LVH) and the Romhilt-Estes points score for LVH was more common in athletes (45% v 23% (p<0.0001) and 10% v 0% (p<0.0001) respectively), as were criteria for left and right atrial enlargement (14% v 1.2% and 16% v 2% respectively). None of the athletes with voltage criteria for LVH had left axis deviation, ST segment depression, deep T wave inversion, or pathological Q waves. ST segment elevation was more common in athletes than non-athletes (43% v 24%; p<0.0001). Minor T wave inversion (less than -0.2 mV) in V2 and V3 was present in 4% of athletes and non-athletes. Minor T wave inversion elsewhere was absent in non-athletes and present in 0.4% of athletes. CONCLUSIONS: ECG changes in junior elite athletes are not dissimilar to those in senior athletes. Isolated Sokolow voltage criterion for LVH is common; however, associated abnormalities that indicate pathological hypertrophy are absent. Minor T wave inversions in leads other than V2 and V3 may be present in athletes and non-athletes less than 16 but should be an indication for further investigation in older athletes. 

PMCID: PMC1756199  PMID: 10522633
22.  Cardiac structure and function in cyclists and runners. Comparative echocardiographic study. 
British Heart Journal  1984;52(2):124-129.
Twelve cyclists and 12 long distance runners matched for age, height, and weight with two control groups of 12 non-athletes were studied echocardiographically to evaluate cardiac structure and function. Runners weighed 8 kg less than cyclists, but age and height were similar. Peak oxygen uptake per kg body weight was higher in athletes than in the control subjects but was similar in the cyclists and in the runners. The athletes' hearts had a larger end diastolic left ventricular internal diameter, mean wall thickness, and cross sectional area of the left ventricular wall than those of the respective control subjects. Nevertheless, whereas the left ventricular internal diameter was not different between the cyclists and runners, mean wall thickness and cross sectional area of the left ventricular wall were greater in the cyclists even after adjustment for weight. The ratio of wall thickness to left ventricular internal radius was significantly larger in cyclists than in their control group, but the ratio was similar in runners and their control group. The echocardiographic indices of left ventricular function were similar in the athletes and the control groups. Systolic left ventricular meridional wall stress was lower in the cyclists than in the runners. The data suggest that runners develop an increase in left ventricular wall thickness which is proportionate to the internal diameter but that in cyclists the increase is disproportionate because of the isometric work of the upper part of the body during cycling.
PMCID: PMC481600  PMID: 6743430
23.  Exercise-Induced Arterial Adaptations in Elite Judo Athletes 
The purpose of this study was to examine exercise-induced arterial adaptations in elite Judo male and female athletes. 27 male Judo athletes (age 24.06 ± 2 years), 11 female Judoka (age 24.27 ± 1 years), 27 sedentary healthy men (age 24.01 ± 2 years) and 11 women (age 24.21 ± 1 years) participated in the current study. The examined vessels included brachial, radial, ulnar, popliteal, anterior and posterior tibial arteries. The experimental parameters were recorded with the use of Duplex ultrasound at rest. Diastolic diameter and blood mean flow velocity of the examined arteries in Judo athletes were found to be both significantly increased (p < 0.05) compared to the findings of the control groups. In male Judo athletes the brachial (p < 0.001), radial (p < 0.001), and anterior tibial artery (p < 0.001) presented the highest difference on the diastolic diameter, compared with the control male group. In female Judo athletes, ulnar (p < 0.001), radial (p < 0.001), and brachial (p < 0.001) arteries illustrated the highest diastolic diameter. The highest blood mean flow velocity was recorded in ulnar (p < 0.001) and popliteal arteries (p < 0.001) of the Judo athletes groups. Recording differences between the two genders, male participants presented larger arteries than females. Conclusively, Judo has been found to be a highly demanding physical sport, involving upper and lower limbs leading to significant arterial adaptations. Obtaining vascular parameters provide a useful tool to the medical team, not only in the direction of enhancement of the efficacy of physical training, but in unknown so far parameters that may influence athletic performance of both male and female elite Judokas.
Key pointsJudo athletes demonstrated a general homogenous increase of the arterial functionality of the upper and lower limbs compared to the control groups.Diastolic diameter found to be significantly increased in male and female Judo athletes, highlighting the effects of exercise training on the vascular system.Judo athletes had had statistically significant increase of the blood mean flow velocity in all examined arteries, compared with the relevant control group.The current study underscores the impact of Judo training on the structure and the function of the arterial system.Clinically, the increased arterial parameters in elite Judo athletes may be essential elements for improved athletic performance.Sports medicine practitioners should give special concern to the vascular functionality for several physiological and medical tests.
PMCID: PMC3763289  PMID: 24150007
Diastolic diameter; blood mean flow velocity; duplex sonography; judo athletes
24.  Bone mass and geometry of the tibia and the radius of master sprinters, middle and long distance runners, race-walkers and sedentary control participants: A pQCT study 
Bone  2009;45(1):91-97.
Mechanical loading is thought to be a determinant of bone mass and geometry. Both ground reaction forces and tibial strains increase with running speed. This study investigates the hypothesis that surrogates of bone strength in male and female master sprinters, middle and long distance runners and race-walkers vary according to discipline-specific mechanical loading from sedentary controls.
Bone scans were obtained by peripheral Quantitative Computed Tomography (pQCT) from the tibia and from the radius in 106 sprinters, 52 middle distance runners, 93 long distance runners and 49 race-walkers who were competing at master championships, and who were aged between 35 and 94 years. Seventy-five age-matched, sedentary people served as control group.
Most athletes of this study had started to practice their athletic discipline after the age of 20, but the current training regime had typically been maintained for more than a decade. As hypothesised, tibia diaphyseal bone mineral content (vBMC), cortical area and polar moment of resistance were largest in sprinters, followed in descending order by middle and long distance runners, race-walkers and controls. When compared to control people, the differences in these measures were always > 13% in male and > 23% in female sprinters (p < 0.001). Similarly, the periosteal circumference in the tibia shaft was larger in male and female sprinters by 4% and 8%, respectively, compared to controls (p < 0.001). Epiphyseal group differences were predominantly found for trabecular vBMC in both male and female sprinters, who had 15% and 18% larger values, respectively, than controls (p < 0.001). In contrast, a reverse pattern was found for cortical vBMD in the tibia, and only few group differences of lower magnitude were found between athletes and control people for the radius.
In conclusion, tibial bone strength indicators seemed to be related to exercise-specific peak forces, whilst cortical density was inversely related to running distance. These results may be explained in two, non-exclusive ways. Firstly, greater skeletal size may allow larger muscle forces and power to be exerted, and thus bias towards engagement in athletics. Secondly, musculoskeletal forces related to running can induce skeletal adaptation and thus enhance bone strength.
PMCID: PMC2832729  PMID: 19332164
Veteran athletes; Track and field runners; Race-walking; Bone strength; Volumetric bone mineral density; Exercise
25.  A New Method for Non-Invasive Estimation of Human Muscle Fiber Type Composition 
PLoS ONE  2011;6(7):e21956.
It has been established that excellence in sports with short and long exercise duration requires a high proportion of fast-twitch (FT) or type-II fibers and slow-twitch (ST) or type-I fibers, respectively. Until today, the muscle biopsy method is still accepted as gold standard to measure muscle fiber type composition. Because of its invasive nature and high sampling variance, it would be useful to develop a non-invasive alternative.
Eighty-three control subjects, 15 talented young track-and-field athletes, 51 elite athletes and 14 ex-athletes volunteered to participate in the current study. The carnosine content of all 163 subjects was measured in the gastrocnemius muscle by proton magnetic resonance spectroscopy (1H-MRS). Muscle biopsies for fiber typing were taken from 12 untrained males.
Principal Findings
A significant positive correlation was found between muscle carnosine, measured by 1H-MRS, and percentage area occupied by type II fibers. Explosive athletes had ∼30% higher carnosine levels compared to a reference population, whereas it was ∼20% lower than normal in typical endurance athletes. Similar results were found in young talents and ex-athletes. When active elite runners were ranked according to their best running distance, a negative sigmoidal curve was found between logarithm of running distance and muscle carnosine.
Muscle carnosine content shows a good reflection of the disciplines of elite track-and-field athletes and is able to distinguish between individual track running distances. The differences between endurance and sprint muscle types is also observed in young talents and former athletes, suggesting this characteristic is genetically determined and can be applied in early talent identification. This quick method provides a valid alternative for the muscle biopsy method. In addition, this technique may also contribute to the diagnosis and monitoring of many conditions and diseases that are characterized by an altered muscle fiber type composition.
PMCID: PMC3131401  PMID: 21760934

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