RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1 NAME OF THE CANDIDATE

AND ADDRESS

Mr. MOHAN.S.

I Year M.Sc Nursing,

Padmashree Institute of Nursing

Kengeri, Bangalore-60

2 NAME OF THE INSTITUTE Padmashree Institute of Nursing

Bangalore

3 COURSE OF THE STUDY AND

SUBJECT

I Year M.Sc Nursing

Child Health Nursing.

4 DATE OF ADMISSION

19-06- 2009

5 TITLE OF THE STUDY

Assessment of effectiveness of

structured teaching programme on

knowledge regarding overuse

syndrome among Adolescents at

selected sports associations

Bangalore.

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

“We are fortunate to have so much talent on the mound. It is a luxury. We won't burn

kids out or overuse them.”1

Physical activity plays a significant role in the well-being of a child. A well-

designed exercise programme enhances the immediate physical, psychomotor and

intellectual attainments of a child. Long-term health benefits depend on continuation of

the physical activity, thus enhancing well-being and favoring the balanced

development of a child.2

The past decade has seen an explosion in the number of children participating

in team and solo sports. At a young age, sport is for enjoyment and for health and

personal development. This balance changes as a competitive element intervenes.

Subsequently, young athletes train harder and longer and participate in sport

throughout the whole year. As an undesired but inevitable consequence, sports-related

injuries have increased significantly. 2

Athletes are specializing in one sport at younger ages. Year-round training puts

more strain on muscle groups without providing the overused muscles sufficient

recovery time.3

One theory behind the increase in sport specialization at younger ages is the

highly competitive market for college scholarships. Young athletes are pushed harder

to be selected to prestigious club teams with the notion that they will have a better

chance of being seen by college coaches. The push results in harder and longer

training for younger and younger athletes. The price paid is a significant increase in

overuse injuries.3

Overuse syndrome is a condition where a part of the body is injured by

repeatedly overusing or exerting too much strain on that body part.4

An overuse injury is micro traumatic damage to a bone, muscle, or tendon that

has been subjected to repetitive stress without sufficient time to heal or undergo the

natural reparative process. 3

An overuse injury is an injury caused by repetitive stress to muscles, tendons,

and connective tissue that does not have time to heal. The tissue is repeatedly stressed

from too much activity resulting in microtears to the connective tissue. If the tissue

does not have a chance to heal from the initial damage, inflammation can set in. This

can result in localized pain, swelling, and point tenderness to the area.3

Overuse injuries can be classified into 4 stages:

1. Pain in the affected area after physical activity

2. Pain during the activity, without restricting performance

3. Pain during the activity that restricts performance

4. Chronic, unremitting pain even at rest.3

Strain occur when body part is called on to work harder, stretch farther, impact

more directly or otherwise functions at a greater level then it is prepared for. The

immediate impact may be minute, but when it occurs repeatedly the constant straining

cause damage.3

The term overuse syndrome identifies a large group of conditions that result

from using the body in a repetitious way and causing injury by the amount it is done.3

These conditions are often focused on a joint and usually affect the muscle,

bone, tendon or bursa of the joint. However other anatomical features and areas can be

stressed and their response to that strain can be an injury.3

Some common examples of overuse syndrome are; carpel tunnel syndrome,

Tendonitis, Bursitis, Tennis Elbow, Trigger Finger, Blackberry Thumb, Shin Splints,

Calluses, Bunyan, Etc…3

Overuse injuries can be prevented through educating coaches and

parents as to the early warning signs of injury. Young athletes need to be monitored

closely for any signs of pain in the shoulder and elbow areas. If pain arises, the

athletes need to have an immediate reduction in the amount and intensity of throwing.3

These types of injuries can also be prevented through providing the athletes

with a proper warm-up (including stretching the muscles that may be at risk for

injury), proper instruction in throwing mechanics, and a slow, gradual, warm-up for

each activity (throwing, pitching). Adding light rotator cuff exercises to the warm-up

can also help by strengthening the small muscles that can be at risk for chronic

injuries.6

Last, the amount that each athlete throws needs to be carefully monitored by

the coaching staff. The number of throws should be age appropriate with care taken to

decrease the number with young athletes and to gradually increase the number of

throws throughout the season. A slow progression of both distance and intensity

should ensure that athletes stay injury free.5

Overuse injuries can be prevented if caught early and managed properly through

the reduction of the activity that caused the initial pain. Athletes with persistent pain

should be referred for medical follow. The following guidelines are suggested to

prevent overtraining/burnout:

1. Keep workouts interesting, with age-appropriate games and training, to keep

practice fun.

2. Take time off from organized or structured sports participation 1 to 2 days per

week to allow the body to rest or participate in other activities.

3. Permit longer scheduled breaks from training and competition every 2 to 3

months while focusing on other activities and cross-training to prevent loss of

skill or level of conditioning. 7

6.2 NEED FOR THE STUDY

Overtraining and burnout among child and adolescent athletes are a growing

problem in the present issue. Although inactivity and obesity are on the rise, the

number of children and adolescents who participate in organized or recreational

athletics has grown considerably over the past 2 decades. It is estimated that 30 to 45

million youth 6 to 18 years of age participate in some form of athletics. Sports

participation is more accessible to all youth, from recreational play and school

activities, to highly organized and competitive traveling teams, to pre-Olympic

training opportunities. 7

The variety of available, organized sporting activities has also grown typical,

such as football, baseball, and soccer, to include, field hockey, rugby, cheerleading,

and dance, each with its own list of sports medicine concerns. This report will assist

the clinician managing young athletes by first defining the medical, psychological, and

developmental concerns of intensive, focused athletic participation. In addition, it will

highlight specific overtraining issues such as participation in endurance events,

weekend athletic tournaments, year-round training on multiple teams, and the

multisport athlete. 7

The incidence of overuse injuries in the young athlete has paralleled the growth

of youth participation in sports. Up to 50% of all injuries seen in pediatric sports

medicine are related to overuse. Because training has become more sport-specific and

nearly continuous, overuse injuries are now common among young athletes recent

data indicat30% to 50% of all pediatric sports injuries are due to overuse . In a study

of children (aged 5 to 17) who presented to a sports injury clinic, 49.5% of 394 sports

injuries were classified as overuse, with boys and girls displaying a similar frequency.

The relative percentage of overuse injuries varies by sport, however. In a 2-year study

of 453 young elite athletes, 60% of swimmers' injuries were due to overuse, compared

to 15% of soccer players' injuries. Athletes who had overuse injuries lost 54% more

time from training and competition than those who had acute injuries.5

Overuse injuries occur when a tissue is injured due to repetitive

submaximal loading. The process starts when repetitive activity fatigues a

specific structure such as tendon or bone. With sufficient recovery, the tissue

adapts to the demand and is able to undergo further loading without injury.

Without adequate recovery, microtrauma develops and stimulates the body's

inflammatory response, causing the release of vasoactive substances,

inflammatory cells, and enzymes that damage local tissue. Cumulative

microtrauma from further repetitive activity ultimately causes clinical injury.

In chronic or recurrent cases, continued loading produces degenerative

changes leading to weakness, loss of flexibility, and chronic pain. Thus, in

overuse injuries the problem is often not acute tissue inflammation, but

chronic degeneration (ie, tendinosis instead of tendinitis). 5

The risks of overuse are more serious in the pediatric/adolescent

athlete for several reasons. The growing bones of the young athlete cannot

handle as much stress as the mature bones of adults. For example, a young

baseball pitcher who has not yet learned proper throwing mechanics (ie,

recruiting the entire kinetic chain—from foot to hand—instead of just the

arm) is at risk of traction apophysitis of the medial elbow. A young gymnast

who performs repetitive hyperextension activities may develop spondylolysis

(ie, a stress fracture of the spine), which is an injury particular to the pediatric

age group. Identifying youth at risk of overuse injuries is the first step to

prevention. Guidelines for parents, coaches, and athletes need to be developed

to provide opportunities for education, injury reduction, and early recognition

of overuse injuries.5

There are physical and physiological differences between children and

adults that may cause children to be more vulnerable to injury. Factors that

contribute to this difference in vulnerability include: children have a larger

surface area to mass ratio, children have larger heads proportionately,

6

children may be too small for protective equipment, growing cartilage may be

more vulnerable to stresses and children may not have the complex motor

skills needed for certain sports until after puberty.6

The most commonly injured areas of the body include the ankle and

knee followed by the hand, wrist, elbow, shin and calf, head, neck and

clavicle. Contusions and strains are the most common injuries sustained by

young athletes. In early adolescence, apophysitis or strains at the apophyses

are common. The most common sites are at the knee (Osgood-Schlatter

disease), at the heel (Sever's disease) and at the elbow (Little League Elbow).

Non-traumatic knee pain is one of the most common complaints in the young

athlete. Patellar Femoral Pain Syndrome (PFPS) has a constellation of causes

that include6

Even though growth plate overuse injuries occur frequently in

adolescents, it is equally important for clinicians and parents to realize that

not all overuse injuries are related to the growth plate and will be something

that a child will "grow out of" or play through. Certain growth plate injuries

may continue to be symptomatic over a long period of time. If early diagnosis

is missed, then healing and significant restrictions on athletic participation

can occur. Neglect may also result in long-term problems," said Frush."It's

important for athletes to work with trainers and their sports medicine

specialists to create a rehabilitation program that safely returns them to an

appropriate level of play once healing occurs." 6

Approximately 3–11% of school children are injured per year while

participating in sport. Twice as many boys as girls sustain sports-related

injuries. Some authors report a similar incidence between the genders. Boys,

however, still sustain more severe injuries, possibly because they are more

aggressive. For certain sports, such as horse riding, injuries are four times

more common in females. While the incidence of sports injuries in several

7

sports are considered, sports involving contact and jumping have the highest

injury levels, Among girls, soccer had the highest injury rate, followed by

basketball, field hockey, softball and volleyball. Elite athletes, however, have

lower injury rates than the general sporting populations. In general, the

incidence of sports injuries seems to increase with age, approaching the

incidence rate of senior players in the older children. 7

The average young tennis player experiences relatively few

severe injuries. If the young tennis player is participating intensely, however,

exclusively in tennis or in tennis and other sports, injuries occur with

increasing frequency. In addition, intensely active young tennis players can

develop deleterious maladaptations in flexibility and strength in areas subject

to repetitive tensile overload these maladaptations have been shown to

increase with years of tournament play. They impose altered joint

biomechanics, and alter muscular force couples around the joint, may be seen

as risk factors for injury causation, and decrease maximal force production. 7

Time spent in learning how to prevent overuse injuries before they set

in is good training for both parents and coaches. In youth sports, the focus

should be on preventing shoulder and elbow injuries. These injuries include

rotator cuff and biceps tendinitis, medial epicondylitis, and instability of the

medial collateral ligament of the elbow.

1. Encourage athletes to strive to have at least 1 to 2 days off per week

from competitive athletics, sport-specific training, and competitive

practice (scrimmage) to allow them to recover both physically and

psychologically.

2. Advice athletes that the weekly training time, number of repetitions,

or total distance should not increase by more than 10% each week (eg,

increase total running mileage by 2 miles if currently running a total of

20 miles per week).

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3. Encourage the athlete to take at least 2 to 3 months away from a

specific sport during the year.

4. Emphasize that the focus of sports participation should be on fun, skill

acquisition, safety, and sportsmanship.

5. Encourage the athlete to participate on only 1 team during a season. If

the athlete is also a member of a traveling or select team, then that

participation time should be incorporated into the aforementioned

guidelines.

6. If the athlete complains of nonspecific muscle or joint problems,

fatigue, or poor academic performance, be alert for possible burnout.

Questions pertaining to sport motivation may be appropriate.

7. Advocate for the development of a medical advisory board for

weekend athletic tournaments to educate athletes about heat or cold

illness, over participation, associated overuse injuries, and/or burnout.

8. Encourage the development of educational opportunities for athletes,

parents, and coaches to provide information about appropriate

nutrition and fluids, sport safety, and the avoidance of overtraining to

achieve optimal performance and good health. 6

An increasing number of children take part in organized sporting

activities, undergoing intensive training and high level competition from an

early age. Although intensive training in children may foster health benefits,

many are injured as a result of training, often quite seriously. This paper

reviews some of the areas of research dealing with intensively trained young

athletes, and focuses on physical, cardiovascular and muscular effects, sports

injuries and psychological effects of intensive training. It is concluded that

measures should be taken to modify present training and competition schemes

to avoid the deleterious effects of intensive physical activity on these

children. 7

9

In light of above facts with the personal experience of the investigator

working as staff in caring adolescents have encountered many injuries

specially sports persons complaints of various injuries. So this has created

interest in investigator to provide a structured teaching programme on

overuse syndrome among Adolescents

6.3 STATEMENT OF THE PROBLEM

A study to assess the effectiveness of structured teaching programme on

knowledge regarding overuse syndrome among Adolescents at selected sports

associations, Bangalore.

6.4 OBJECTIVES

1 .To assess the pretest knowledge regarding Overuse syndrome among

Adolescents.

2. To assess the post test knowledge regarding Overuse syndrome among

Adolescents.

3. To evaluate the effectiveness of structured teaching programme on

Overuse syndrome among Adolescents.

4. To associate post test knowledge regarding Overuse syndrome among

Adolescents with their selected demographic variables.

6.5 OPERATIONAL DEFINITIONS

1. Knowledge:

It refers to level of understanding regarding overuse syndrome among

Adolescents

2. Effectiveness:

It refers to the improvement in knowledge on Overuse syndrome among

Adolescents.

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3. Structured teaching programme:

It refers to systematically organized teaching strategy for duration of 45 mins

to one hour on Overuse syndrome, its definition, causes, injuries and

prevention among Adolescents, by verbal interaction with the use of flash

cards.

4. Overuse syndrome:

It is a condition where a part of the body is injured by repeatedly overusing or

exerting too much strain on that body part.

5. Adolescents:

Adolescents are undergoing training in sports association of age group

between thirteen to nineteen years.

.

ASSUMPTIONS

1. Adolescents may have inadequate knowledge regarding Overuse syndrome

2. Structured teaching programme will improve the knowledge regarding

Overuse syndrome among Adolescents.

3. Adolescent’s knowledge may vary with their selected demographic

variables.

6.7 RESEARCH HYPOTHESES

H1: There is a significant difference between mean pre test and post test

knowledge regarding Overuse syndrome among Adolescents.

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H2: There is a significant association between the knowledge of the

Adolescents with their selected demographic variable.

6.8 REVIEW OF LITERATURE

ORTON Research Institute, ORTON Foundation, Helsinki, Finland

conducted Twelve-month retrospective study on Gender differences in sport

injury risk and types of injuries among cross-country skiers, swimmers, long-

distance runners and soccer players. This twelve months survey compared

injury risk and injury types by genders (312 females, 262 males) .More male

than female runners reported at least one Overuse injury After adjustment for

sport event males were at increased risk for posterior thigh Overuse injuries

compared to females while females were at increased risk for overuse injuries

in the ankle compared to males After adjustment for exposure time

(injuries/1000 exposure hours) significance of the difference between the

sexes in Overuse injury to the ankle persisted. they conclude there are some

gender differences in sport- injuries.8

A study done on to determine the relationship between lower extremity

alignment and MTSS amongst non-professional athletes in a prospective

Study, sixty six subjects were evaluated. Runners were followed for 17 weeks

to determine occurrence of MTSS .The overall injury rate for MTSS was

19.7%. The MTSS injury rate in girls (22%) was not significantly different

from the rate in boys (14.3%). Most MTSS injuries were induced after 60

hours of exercise, which did not differ between boys and girls. There was a

significant difference in right and left navicular drop (ND) in athletes with

MTSS.9

Musculoskeletal Research Centre and School of Physiotherapy,

La Trobe University, Victoria, Australia conducted a study on volume of

physical activity and injury occurrence in young basketball players. Detailed

physical activity and injury data were prospectively collected in 46 school-

12

level basketball players aged 14 to 18 years. Results showed that athletes who

specifically sustained overuse injuries (p = 0.01) participated in a greater

amount of basketball refereeing than uninjured athletes. 10

A study was done to examine whether bowling workload is a risk

factor for overuse injury to Australian junior cricket fast bowlers and to

evaluate the appropriateness of current bowling workload guidelines.

Bowling workload prior to the first injury (for those bowlers who were

injured) was compared to workload across the whole season for uninjured

bowlers. Results: Eleven (25%) bowlers reported an overuse-type injury, with

seven of these sustaining a back injury. Increased risk of injury for those who

bowled an average of ≥2.5 days per week or ≥50 deliveries per day .This

study has identified high bowling workload as a risk factor for overuse injury

to junior fast bowlers. 11

Department of Trauma and Orthopaedic Surgery, Keele University

School of Medicine, UK, conducted a study on Sports injuries in children.

Sports injuries in children affect both growing bone and soft tissues, and can

result in damage of growth mechanisms with subsequent lifelong, growth

disturbance. During growth, there are significant changes in the

biomechanical properties of bone. In young athletes, as bone stiffness

increases and resistance to impact diminishes, sudden overload may cause

bones to bow or buckle. Fractures that are initially united with some

deformity can completely remodel, and the bone may appear totally normal in

later life.12

A study was done on Swimming overuse injuries. Swimming injuries

are unique in that they involve upper limb overuse more than lower limbs and

that swimming is performed in a non-weight-bearing fluid setting. Identifying

the mechanism of injury and prescribing appropriate management is not easy

unless one has a thorough understanding of proper technique of the four

competitive strokes. Understanding the psychology of swimming athletes will

13

improve outcome and compliance. The goals of this article are to familiarize

the reader with the diagnosis and management of swimming injuries and to

improve the physician's effectiveness in dealing with swimmers through a

thorough understanding of technique and psychology. 13

The Research Station of Sports Medicine, Tampere, Finland

Conducted a 30-month prospective follow-up study of children's overuse

injuries at an outpatient sports clinic was carried out to determine the number,

profile, and specific features of these injuries compared with those of young

adults. During this period 74 athletically active boys ( 15 years), 83 girls, 255

men (21-30 years), and 77 women visited the station because of an overuse

sports injury of the musculoskeletal system. In girls and women, the lower

back (13%) was significantly more frequently affected than in boys and men

(6%).Thirty two percent of all boys' overuse problems were classified as

exercise-induced growth disorders and osteochondritic pains (apophysitides,

etc.), but in girls only 13% had a similar basis. 14

  A study was done to determine whether there are significant

differences in the causes of back pain in young athletes compared with the

general adult population and to review the diagnosis and assessment of young

athletic adolescent patients who present with this complaint. Forty-seven

percent of the 100 adolescents were ultimately shown to have a spondylolysis

stress fracture of the pars interarticularis. By contrast, 5% of adult subjects

were found to have spondylolysis associated with low back pain. Similarly,

discogenic back pain was the final diagnosis in 48 of the 100 subjects in the

adult group, while 11 of the 100 in the adolescent group had back pain

attributable to disc abnormalities. 15

An 8-Season Prospective Study done on Injuries in Young Elite Female

Soccer Players, Injuries sustained by players between 15 and 19 years of age,

during 8 seasons, Altogether 619 injuries were documented for 110 players

(92.4%). Of these injuries, 64.6% were sustained during training and

14

matches, respectively. The risk of injury was greater in the youngest (under

age 15) group compared with the oldest (under 19) group and 83 (13.4%)

were overuse injuries. There were 51.9% minor injuries, 35.7% moderate

injuries, and 12.4% major injuries.16

A study was done on Overuse Injuries in Female Athletes. The last

three decades have witnessed a tremendous increase in female sports

participation at all levels. However, increased sports participation of female

athletes has also increased the incidence of sport-related injuries, which can

be either acute trauma or overuse injuries. This study reviews the most

frequent overuse injuries in female athletes in the context of anatomical,

physiological, and psychological differences between genders. Although

injuries tend to be sport-related rather than gender-related, it has been noted

that certain conditions, such as patellofemoral pain syndrome, stress

fractures, or lateral epicondylitis are especially prevalent in female athletes .17

A Prospective Study was done to evaluate prospectively leg length

discrepancy, hip flexor tightness, and lower extremity acquired laxity or

overuse as predictive factors for low back pain in college athletes. Two-

hundred fifty-seven college athletes representing nine varsity sports were

screened during a preseason sports physical examination. Results were

Twenty-four athletes (9.3%) received treatment for low back pain. Thirteen of

87 women (15%) compared with 11 of 170 men (6%) required treatment for

low back pain (P = 0.048). Of 57 athletes with lower extremity acquired

laxity or overuse, low back pain developed in 14 (P < 0.001), conclude that

Athletes with lower extremity acquired ligamentous laxity or overuse may be

at risk for the development of noncontact low back pain during athletic

competition.18

A study was done on running Overuse injuries. It is the primary culprit

in most running injuries, with biomechanical factors playing a much smaller

role. Non-musculoskeletal events that may be related to a musculoskeletal

15

injury such as exercise-associated amenorrhea and chronic fatigue or

depression are reviewed. That running may promulgate osteoarthritis is still

controversial. However, the preponderance of data gives insufficient credence

to the idea of osteoarthritis as a complication of long-distance running. With

regard to treatment, nonsteroidal anti-inflammatory drugs appear to play little

or no effective role in the management of running injuries19

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected, from the Adolescents at selected sports

associations Bangalore.

7.2 METHODS OF COLLECTION OF DATA

i. Research design

Quasi-Experimental - one group pretest posttest design

ii. Research variables

Dependent variables:

Level of knowledge regarding overuse syndrome among Adolescents

.

Independent variables:

Structured teaching programme on knowledge regarding overuse syndrome

among Adolescents

iii. Setting

The study will be conducted at selected sports associations Bangalore.

16

iv. Population

All the Adolescents of age group between thirteen to eighteen years in

selected sports associations Bangalore.

v. Sample

Adolescents who fulfill inclusion criteria and the sample size will be 60.

vi. Criteria for sample selection

Inclusion criteria:

The study includes:

1. Adolescents are undergoing training in sports association

2. Adolescents of age group between thirteen to nineteen years.

3. Adolescents who are available at the time of data collection.

Exclusion criteria:

The study will exclude:

1. Adolescents, who cannot understand Kannada or English language.

2. Adolescents who are not willing to participate

vii. Sampling technique

Non- probability convenient sampling technique.

viii. Tool for data collection

The tool consists of two sections:

Section A:

Demographic variable such as age, sex, education, type of sports,

religion, occupation of parents, duration of practice, food pattern

17

Section B:

Structured questionnaire is used to assess the knowledge on Adolescents

regarding Overuse syndrome.

ix. Method of data collection.

After obtaining the permission from the concerned authorities and

informed consent from the samples the investigator will collect the data in

following three phases.

Phases-One - Pre test will be given to assess the existing knowledge on

Adolescents regarding Overuse syndrome with the help of structured

questionnaire.

Phases-Two - On the same day structured teaching programme will be given

to Adolescents on Overuse syndrome by using flash card for 45mt -1 hr

duration.

Phases-Three - Same questionnaire will be administered to Adolescents on

Overuse syndrome, after 7 days.

Duration of the data collection is 4 to 6 weeks.

x. Plan for data analysis

The data collected will be analyzed by means of descriptive statistics and

inferential statistics.

Descriptive statistics:

Frequency and percentage distribution of demographic variables will be

analyzed. Mean, and standard deviation will be used to assess the level of

knowledge of Adolescents regarding Overuse syndrome.

18

Inferential statistics:

Paired-'t' test will be used to compare the pretest and posttest knowledge

regarding Overuse syndrome among Adolescents; chi-square test will be used

to associate posttest knowledge on Overuse syndrome of Adolescents with

selected demographic variable.

xi. Projected outcome

Structured teaching will improve the knowledge of Adolescents

regarding Overuse syndrome. This will enable the Adolescents to improve

their self-help skills in their activities of daily living.

7.3 Does the study require any investigation or interventions to be

conduct on patients or other human or animals?

Yes, structured teaching programme will be administered for Adolescents on

Overuse syndrome in selected sports associations, Bangalore.

.

7.4 Has ethical clearance been obtained from your institution?

Yes, permission will be obtained from concerned authority and informed

consent will be obtained from samples.

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19

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4. Dorothy R Marlow, Barbara, A Redding Text book of pediatric nursing;

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journal of sports medicine, vol 39, 843-846 

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11. Chezhiyan Shanmugam and Nicola Maffulli, Sports injuries in

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.Department of Trauma and Orthopaedic Surgery, Keele University School

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