Sport Psychology in Sports Medicine
Continuing Education Workshop AASP 2009
Sharon A. Chirban, Ph.D.Sport Psychologist
Division of Sports Medicine
Children’s Hospital Boston
Harvard Medical School
Sports Medicine
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Youth Sports– Less Free Play
– Greater Intensity
– Higher Competitive Levels
– Single Sport Focus
– Parents, Coaches, Scouts
– $
– Goals: Kids vs Adults
Benefits of Youth Exercise– Medical
• Obesity
• Diabetes
• Cardiovascular risk
• Bone Health
– Psychosocial• Self-esteem
• Teen Pregnancy
• Recreational Drug Use
Pediatric Athlete– “Child is not a little adult.”
– “Child athlete is not a little adult athlete.”
First & Foremost Pediatric Sports Medicine Clinic– 20,000 patient visits per year
– 2,500 surgeries per year Staff
– Orthopaedic Surgeons
– Primary Care Physicians
– Sports Podiatrists• Athletic Trainers
• Sports Pyschology
• Nutritionists
• Exercise Physiology
Introduction
Division of Sports Medicine
Research– Clinical Research
• ACL Injuries
• Osteochondritis Dissecans
• Stress Fractures
• Spondylolysis
• Rugby Injuries
– Basic Science• ACL primary healing
Introduction
Division of Sports Medicine
Community Outreach– School Coverage
• 6 Colleges• 18 High Schools
– Boston Public Schools Sports Medicine Initiative
– Boston Ballet– Performing Arts– Track & Field– Baystate Games– Sports Camps– US Figure Skating
Introduction
Division of Sports Medicine
Overview of Workshop
The role of a sports psychologist in treating sports medicine patients
Discuss issues around professional development and integration
Discuss working in a medical milieu and working on a treatment team
An overview of sports medicine clinical topics Case presentations will be used as a teaching tool for
participants.
Role of a sports psychologist in treating sports medicine patients
SP is licensed within Sports Medicine Department
SP works in coordination with primary care sports med physicians, orthopedic surgeons, physical therapists, athletic trainers, nutritionists, fellows and interns in training
Associated University affiliation coverage Event Coverage
Clinical Issues in Sports Medicine
Acute Injuries
vs
Overuse Injuries
Acute Injury
Fracture Contusion Sprain Strain Concussion
Overuse Injury
Stress Fracture Tendinopathy Chondromalacia Bursitis Fascitis
Risk Factors
•Host•Environmental
Risk Factors: Sport Injuries
HOST Anatomic Alignment Muscle Tendon Imbalance Fitness Level Growth and Maturation Nutrition Gender
Risk Factors: Sport Injuries
ENVIRONMENTAL Training Conditioning Surface Footwear Equipment Coaching
Training: Environmental Factor
Sports Training– The young athlete– How much is too much?– How much is enough?
Overtraining
Performance Fatigue Growth Endocrine Injury
Overuse Syndrome
Types of Training Amount of Training Rate of Training
Case Report
15 year-old “Clara” Boston Ballet Chronic back pain RSD/Perfectionistic Personality Two years of counseling Back to ballet
Female Athlete Triad
Amennorhea Osteopenia Disordered Eating
Overuse Injury: Stress Fracture
Cases
Eating Disordered Athletes– Karyn
Athletes with Eating Disorders– Boston College Runner
Preadmission InformationSummer 2003
17 year old Cross country scholarship athlete was preparing to matriculate September 2003
Coaches intercepted series of photos on the internet
Female Athlete Triad
Pierre d’Hemecourt, MD
Preadmission InformationSummer 2003
17 year old Cross country scholarship athlete was preparing to matriculate September 2003
Coaches intercepted Series of photos on the internet
September 2002(Senior High School Year)
November 2002(Senior High School Year)
January 2003(Senior High School Year)
June 2003(Senior High School Year)
Preparticipation Evaluation
PMD office notes 2/03 wt = 110PMD office notes 7/14 wt = 90
Initial evaluation 8/25/03No hx of eating disorder or depressionHX of elevated cholesterolHx lactose intoleranceMenarche at age 15 but no menses
since August 2002Denies purgePE
Wt = 83, Ht 61, BMI = 15.7BP 87/60, P 56
Initial Lab
EKG normal with QT interval 0.4
HCT/ Hgb = 39.1/14.1BUN/Cr =15/.8Chol=249, Tg = 149LFT’s normalEstradiol<32LH<.7FSH<.7Ferritin=6
TSH = 3.5Free thyroxin =.7Prolactin: 6.06
ng/mLPTH = 3725- OHD=28Ca 9.9MG 2.2
DecisionHome vs. intense care on
campus
Contract signed that stipulated:
Weekly Health Service visitsWeekly gain of 1-2 lb (wts in
shorts and tank top)Weekly Counseling visitsEvery 2 weeks nutritionistNo exercise
Counseling
Nutrition MedicalMonitoring
ATC
Freshman Year 1st SemesterDate Weight Urine SG Comments
9/5 86 1.003
9/12 87 1.005
9/16 90.5 1.004 Roommate trouble
9/30 95.25 1.008 Roommate trouble
10/7 96.25 1.006 Start Wt training
Light run
10/17 98 1.004
10/25 98 1.001 Run 5 mi QOD
11/21 100 BMI = 18.4
1.007 Run 30 mi/wk
Low bone density
Lumbar Z= -2.1
Freshman 2nd SemesterDate Weight Urine SG Comments
1/16 103.5 BMI= 19.6
1.020 Cleared for Track
Limit 40 mi/wk
2/16 106.5 1.023
3/05 104 1.019
3/16 102 1.020 Warned
3/23 103 1.017 Mild T-L pain→PT
4/20 104 1.117 Pain Cleared
5/5/04 104 1.023 Thoracic and sacral pain
Bone Scan
Sacral Stress fracture
Mild compressions at T7 and T8
Summer 04 (Freshman-Sophomore)
No running for 2 monthsJuly started running 10 mi/ wkSaw orthopedist for recurrent pain in early
August and MRI showed new right sacral stress fracture
Started her on Actonel 35 mg per week
Instructed to not run for 3 months: August, September and October
Sophomore Year 1st Semester
Date Weight Urine SG Comments
9/08/04 104.5
10/07 104 1.017 Noted to cry a lot
11/9 99.75 1.019 Run 15 min QOD
11/16 100 1.022 ETOH/? Purge
11/23 100 BMI= 18.9
1.025
12/17 101 Run 35 min 3x/wk
Instructions given for gradual increase over break
Repeat DEXA NoΔ
Lumbar Z = -2.1
Hip Z = - 1.5
Sophomore Year 2nd Semester
Date Weight Urine SG Comments
1/21/05 110 1.015 Great Affect
Mild sacral pain
MRI (-)
2/2 108 No Pain
2/18 108 Runs 37 mi/ wk
Mild intermittent non impact pain through the semester but tolerated increased running to 40 mi wk.Some alcohol abuse was reported.That summer developed a tibial plateaux non displaced stress fracture
Summer Sophomore- Junior Year
That summer developed a tibial plateau non displaced stress fracture
fracture and cross trained all summer
Junior Year 1st Semester
No pain on return, normal exam including jump test
Uneventful semester maintaining wt at 110 with minimal pain
Ran modified with team, about 4 times per week to a max of 25 miles per wk
Junior Year 2nd SemesterDEXA repeated and showed increased density
Hip ↑ 4.4% to Z score of -1.2Lumbar ↑ 2.2% (not clinically significant) to Z -2.1
Stable weight about 115Some hip and tibia pain with a normal bone scan in
FebruaryProgressed to 50 miles per wk. SI pain with negative MRI except L5-S1 discSummer had successful SI injection
Senior Year 2006-2007
Maintained her wt well
Running about 40 mi/wk
November developed a left tibial stress fracture
Now with right tibial pain
Female Athlete Triad
Studies have found that 15 to 62% of female college athletes have disordered eating.
3.4 to 66% of female athletes are amenorrheic.
At least 90% of peak bone mass is acquired by age 18.
Female Athlete Triad
OLD THEORYDisordered eating and/or excessive exercise →Low body weight and low body fat →Amenorrhea → Low estrogen →Decreased calcium absorption and utilization →Low bone density
Negative Energy Balance →Disruption of HPO axis
Leptinpolypeptide secreted by adipocytes,
with receptors on hypothalamus and bone!1 Helps regulate food intake, energy expenditure, growth, sexual
maturation, and likely GnRH/LH pulsitility.2
Evidence of absence of diurnal leptin levels in amenorrheic, high level athletes.3
Possible negative central effects and positive peripheral effects.4
1 Bradley SJ, Taylor MJ, Rovet JF, et al. Assessment of brain function in adolescent anorexia nervosa before and after weight gain. J Clin Exper Neuropsych 19(1): 20-33, 1997.
2 Cheung CC, Thornton JE, Kuijper JL, et al. Leptin is a metabolic gate for the onset of puberty in the female rat. Endocrinology 138(2):855-8, 1997.3 Laughlin GA, Yen SCC. Hypoleptinemia in women athletes: absence of diurnal rhythm with amenorrhea.
J Clin Endocrinol Metab 82(1):318-21, 1997.
4 Burguera B, Hofbauer LC, Thomas T, et al. Leptin reduces ovariectomy-induced bone loss in rats. Endocrinology 142(8):3546-53, 2001.
IMPROVING DETECTION OF
Awareness in PPEs:Menstrual HistoryHistory of Stress FracturesCalcium Intake and Vitamin D intake
Frequent Follow-up:Labs and radiologic testingMore extensive H & P: Mood, Stressors, Diet, Cardiac exam,
Tanner stage, Hair growth
IMPROVING TREATMENT OF
Medical/Nutritional/Psychiatric Teamwork
Coach/Trainer/Athletic Department/Family support and awareness
IMPROVING TREATMENT OF
Hormonal Therapy- Currently NO pharmacologic tx approved by FDA for premenopausal women that improve bone formation.
Future Options?:Bisphosphonates (ex: Fosamax, Actonel, Boniva)Selective Estrogen Receptor Modulators (SERMs- ex. Raloxifene and
Tamoxifene)Parathyroid analogs (ex: Forteo)Black Cohosh- animal studies and human osteoblasts (osteoprotegrin)Leptin
Thank You
Fitness: Environmental Risk Factor
Cardiovascular/Metabolic Musculoskeletal
– Strength– Flexibility– Endurance
Body Composition Psychological
Head InjuriesPost Concussive Syndrome
Delayed responseDistractedDisorientedCoordination issuesEmotional labilityMemory deficitAmnesia
Second Impact Syndrome SIS
Occurs mostly in the adolescent 14-16A second head injury(often minor) is sustained while
still symptomatic from the first injuryAltered cerebral autoregulation malignant brain
edemaStable for 15 seconds to minutes precipitous
collapse, comatose, respiratory failureRapid intubation and osmotic diuresis(mannitol)
Cantu 1986American Academy of Neurology Grade I -No LOC,
amnesia 30 minutesGrade II - LOC 5min
or amnesia 30 min but 24 hrs
Grade III -LOC 5 min or amnesia 24 hrs
Grade I- No LOC, transient confusion less than 15 minutes
Grade II- No LOC, transient confusion more than 15 min
Grade III- LOC
AAN Return to Play Guidelines
Grade I: May return to play if symptoms clear within 15 minutes
Grade II: Terminate contest. May return to play if no symptoms on exertion for one week
Grade III: Terminate contest. May return to play after one week without symptoms if LOC < 1 min or 2 weeks if LOC > 1min (consider hospital evaluation)
Return to Play with a Second Concussion
Grade I: Terminate contest and return after one week without symptoms at rest and exertion
Grade II: Terminate contest and return after 2 weeks without symptoms at rest and exertion
Grade III: Return after one month without symptoms at rest and exertion
Return To Play
Recommend injury grading in retrospect
Symptom scoresQuestion the significance of
loss of consciousnessSignificance of amnesiaPediatric considerations
Symptom Scores
Headache
Neck pain
Balance or dizziness
Nausea
Visual difficulty
Hearing abnormally
Dazed
Confused
Feeling confused
Feeling in a fog
Drowsiness
Fatigue
Emotional lability
Difficulty concentration
Difficulty remembering
Trouble sleeping
Concussion Cases
Nick soccer player
Hannah hockey Player
Gigi cheerleader
Upper Extremity OveruseShoulder Syndromes
Labal tears: poppingInstability: subluxation
or dead arm feelingImpingement: painful
archBiceps tendonitis:
anterior painAC joint: impingement
Upper Extremity OveruseSwimmers Shoulder
Constellation of instability and impingement
Training may require 10 to 15 thousand yards per day.
75% of this may be freestyleMcMaster and Troup found
shoulder pain in: 10% of age 13- 14 13% of age 15- 16 26% of elite college swimmers
Upper Extremity OveruseSwimmers Shoulder
Inflammation in the supraspinatus and/or biceps tendons usually caused by glenohumeral instability
Supraspinatus ischemia at the end of the pull phase
Upper Extremity OveruseSwimmers Shoulder
DiagnosisHistory of pain at
which part of the stroke
Signs of impingement and instability
Signs of rotator cuff weakness and inflexibility
Upper Extremity OveruseSwimmers Shoulder
TreatmentRelative rest but
not deconditioned
Some pool work
Address rotator cuff stabilization
Upper Extremity OveruseSwimmers Shoulder
TreatmentTechnique:
1)Finish of the stroke so that the arm exits the water at the iliac crest 2)Roll 70-90 degrees 3) Entry just outside the line of the shoulder
Upper Extremity OveruseSwimmers Shoulder
Prevention
10% rule for increase in volume of time and intensity
Weight train with attention to the rotator cuff
Cross training
Make it or Break it