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Sport Psychology in
Sports Medicine
Continuing Education Workshop AASP 2009
Sharon A. Chirban, Ph.D.
Sport Psychologist
Di...
Sports Medicine
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QuickTime™ and a
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 Youth Sports
– Less Free Play
– Greater Intensity
– Higher Competitive Levels
– Single Sport Focus
– Parents, Coaches, S...
 Benefits of Youth Exercise
– Medical
• Obesity
• Diabetes
• Cardiovascular risk
• Bone Health
– Psychosocial
• Self-este...
 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
– ...
 Research
– Clinical Research
• ACL Injuries
• Osteochondritis Dissecans
• Stress Fractures
• Spondylolysis
• Rugby Injur...
 Community Outreach
– School Coverage
• 6 Colleges
• 18 High Schools
– Boston Public Schools Sports
Medicine Initiative
–...
Overview of Workshop
 The role of a sports psychologist in treating sports
medicine patients
 Discuss issues around prof...
Role of a sports psychologist in
treating sports medicine patients
 SP is licensed within Sports Medicine
Department
 SP...
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
...
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 cou...
Female Athlete Triad
 Amennorhea
 Osteopenia
 Disordered Eating
Overuse Injury: Stress Fracture
Cases
 Eating Disordered Athletes
– Karyn
 Athletes with Eating Disorders
– Boston College Runner
Preadmission Information
Summer 2003
17 year old Cross country
scholarship athlete was preparing
to matriculate September ...
Female Athlete Triad
Pierre d’Hemecourt, MD
Preadmission Information
Summer 2003
17 year old Cross country
scholarship athlete was preparing
to matriculate September ...
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 =
110
PMD office notes 7/14 wt =
90
Initial evaluation 8/25/03
No hx ...
Initial Lab
EKG normal with QT
interval 0.4
HCT/ Hgb =
39.1/14.1
BUN/Cr =15/.8
Chol=249, Tg = 149
LFT’s normal
Estradiol<3...
Decision
Home vs. intense care
on campus
Contract signed that
stipulated:
Weekly Health
Service visits
Weekly gain of 1-2 ...
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 9...
Freshman 2nd
Semester
Date Weight Urine SG Comments
1/16 103.5
BMI= 19.6
1.020 Cleared for
Track
Limit 40
mi/wk
2/16 106.5...
Bone Scan
Sacral Stress
fracture
Mild compressions
at T7 and T8
Summer 04
(Freshman-Sophomore)
No running for 2 months
July started running 10 mi/ wk
Saw orthopedist for recurrent pain i...
Sophomore Year 1st
SemesterDate 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...
Sophomore Year 2nd
SemesterDate Weight Urine SG Comments
1/21/05 110 1.015 Great Affect
Mild sacral
pain
MRI (-)
2/2 108 N...
Summer Sophomore- Junior Year
That summer developed a tibial
plateau non displaced stress
fracture
fracture and cross trai...
Junior Year 1st
Semester
No pain on return, normal exam
including jump test
Uneventful semester maintaining wt at
110 with...
Junior Year 2nd
Semester
DEXA repeated and showed increased
density
Hip ↑ 4.4% to Z score of -1.2
Lumbar ↑ 2.2% (not clini...
Senior Year 2006-2007
Maintained her wt
well
Running about 40
mi/wk
November
developed a left
tibial stress
fracture
Now w...
Female Athlete Triad
Studies have found
that 15 to 62% of
female college
athletes have
disordered eating.
3.4 to 66% of fe...
Female Athlete Triad
OLD THEORY
Disordered eating and/or excessive exercise →
Low body weight and low body fat →
Amenorrhe...
Negative Energy Balance →
Disruption of HPO axis
Leptin
polypeptide secreted by adipocytes,
with receptors on hypothalamus...
IMPROVING DETECTION OF
Awareness in PPEs:
Menstrual History
History of Stress Fractures
Calcium Intake and Vitamin D intak...
IMPROVING TREATMENT OF
Medical/Nutritional/Psychiatric Teamwork
Coach/Trainer/Athletic Department/Family
support and aware...
IMPROVING TREATMENT OF
Hormonal Therapy- Currently NO
pharmacologic tx approved by FDA for
premenopausal women that improv...
Thank You
Fitness:
Environmental Risk Factor
 Cardiovascular/Metabolic
 Musculoskeletal
– Strength
– Flexibility
– Endurance
 Bod...
Head Injuries
Post Concussive Syndrome
Delayed response
Distracted
Disoriented
Coordination issues
Emotional lability
Memo...
Second Impact Syndrome
SIS
Occurs mostly in the adolescent 14-16
A second head injury(often minor) is sustained while
stil...
Cantu 1986American Academy of Neurology
Grade I -No LOC,
amnesia < 30
minutes
Grade II - LOC <
5min or amnesia >
30 min bu...
AAN Return to Play Guidelines
Grade I: May return to play if symptoms clear within
15 minutes
Grade II: Terminate contest....
Return to Play with a
Second Concussion
Grade I: Terminate contest and return after
one week without symptoms at rest and
...
Return To Play
Recommend injury grading in
retrospect
Symptom scores
Question the significance of
loss of consciousness
Si...
Symptom Scores
Headache
Neck pain
Balance or dizziness
Nausea
Visual difficulty
Hearing abnormally
Dazed
Confused
Feeling ...
Concussion Cases
Nick soccer player
Hannah hockey Player
Gigi cheerleader
Upper Extremity Overuse
Shoulder Syndromes
Labal tears: popping
Instability:
subluxation or dead
arm feeling
Impingement: ...
Upper Extremity Overuse
Swimmers Shoulder
Constellation of instability
and impingement
Training may require 10 to
15 thous...
Upper Extremity Overuse
Swimmers Shoulder
Inflammation in the
supraspinatus and/or
biceps tendons
usually caused by
glenoh...
Upper Extremity Overuse
Swimmers Shoulder
Diagnosis
History of pain at
which part of the
stroke
Signs of impingement
and i...
Upper Extremity Overuse
Swimmers Shoulder
Treatment
Relative rest but
not deconditioned
Some pool work
Address rotator
cuf...
Upper Extremity Overuse
Swimmers Shoulder
Treatment
Technique:
1)Finish of the
stroke so that the
arm exits the water
at t...
Upper Extremity Overuse
Swimmers Shoulder
Prevention
10% rule for increase
in volume of time
and intensity
Weight train wi...
Make it or Break it
SPORTS PSYCHOLOGY IN SPORTS MEDICINE
SPORTS PSYCHOLOGY IN SPORTS MEDICINE
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SPORTS PSYCHOLOGY IN SPORTS MEDICINE

  1. 1. 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
  2. 2. Sports Medicine
  3. 3. QuickTime™ and a decompressor are needed to see this picture.
  4. 4. QuickTime™ and a decompressor are needed to see this picture.
  5. 5.  Youth Sports – Less Free Play – Greater Intensity – Higher Competitive Levels – Single Sport Focus – Parents, Coaches, Scouts – $ – Goals: Kids vs Adults
  6. 6.  Benefits of Youth Exercise – Medical • Obesity • Diabetes • Cardiovascular risk • Bone Health – Psychosocial • Self-esteem • Teen Pregnancy • Recreational Drug Use
  7. 7.  Pediatric Athlete – “Child is not a little adult.” – “Child athlete is not a little adult athlete.”
  8. 8.  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
  9. 9.  Research – Clinical Research • ACL Injuries • Osteochondritis Dissecans • Stress Fractures • Spondylolysis • Rugby Injuries – Basic Science • ACL primary healing Introduction Division of Sports Medicine
  10. 10.  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
  11. 11. 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.
  12. 12. 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
  13. 13. Clinical Issues in Sports Medicine Acute Injuries vs Overuse Injuries
  14. 14. Acute Injury  Fracture  Contusion  Sprain  Strain  Concussion
  15. 15. Overuse Injury  Stress Fracture  Tendinopathy  Chondromalacia  Bursitis  Fascitis
  16. 16. Risk Factors •Host •Environmental
  17. 17. Risk Factors: Sport Injuries HOST  Anatomic Alignment  Muscle Tendon Imbalance  Fitness Level  Growth and Maturation  Nutrition  Gender
  18. 18. Risk Factors: Sport Injuries ENVIRONMENTAL  Training  Conditioning  Surface  Footwear  Equipment  Coaching
  19. 19. Training: Environmental Factor  Sports Training – The young athlete – How much is too much? – How much is enough?
  20. 20. Overtraining  Performance  Fatigue  Growth  Endocrine  Injury
  21. 21. Overuse Syndrome  Types of Training  Amount of Training  Rate of Training
  22. 22. Case Report  15 year-old “Clara”  Boston Ballet  Chronic back pain  RSD/Perfectionistic Personality  Two years of counseling  Back to ballet
  23. 23. Female Athlete Triad  Amennorhea  Osteopenia  Disordered Eating Overuse Injury: Stress Fracture
  24. 24. Cases  Eating Disordered Athletes – Karyn  Athletes with Eating Disorders – Boston College Runner
  25. 25. Preadmission Information Summer 2003 17 year old Cross country scholarship athlete was preparing to matriculate September 2003 Coaches intercepted series of photos on the internet
  26. 26. Female Athlete Triad Pierre d’Hemecourt, MD
  27. 27. Preadmission Information Summer 2003 17 year old Cross country scholarship athlete was preparing to matriculate September 2003 Coaches intercepted Series of photos on the internet
  28. 28. September 2002 (Senior High School Year)
  29. 29. November 2002 (Senior High School Year)
  30. 30. January 2003 (Senior High School Year)
  31. 31. June 2003 (Senior High School Year)
  32. 32. Preparticipation Evaluation PMD office notes 2/03 wt = 110 PMD office notes 7/14 wt = 90 Initial evaluation 8/25/03 No hx of eating disorder or depression HX of elevated cholesterol Hx lactose intolerance Menarche at age 15 but no menses since August 2002 Denies purge
  33. 33. Initial Lab EKG normal with QT interval 0.4 HCT/ Hgb = 39.1/14.1 BUN/Cr =15/.8 Chol=249, Tg = 149 LFT’s normal Estradiol<32 LH<.7 TSH = 3.5 Free thyroxin =.7 Prolactin: 6.06 ng/mL PTH = 37 25- OHD=28 Ca 9.9 MG 2.2
  34. 34. Decision Home vs. intense care on campus Contract signed that stipulated: Weekly Health Service visits Weekly gain of 1-2 lb (wts in shorts and tank top) Weekly Counseling Counseling Nutrition Medical Monitoring ATC
  35. 35. 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
  36. 36. Freshman 2nd Semester Date 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
  37. 37. Bone Scan Sacral Stress fracture Mild compressions at T7 and T8
  38. 38. Summer 04 (Freshman-Sophomore) No running for 2 months July started running 10 mi/ wk Saw 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:
  39. 39. Sophomore Year 1st SemesterDate 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
  40. 40. Sophomore Year 2nd SemesterDate 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
  41. 41. Summer Sophomore- Junior Year That summer developed a tibial plateau non displaced stress fracture fracture and cross trained all summer
  42. 42. 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
  43. 43. Junior Year 2nd Semester DEXA repeated and showed increased density Hip ↑ 4.4% to Z score of -1.2 Lumbar ↑ 2.2% (not clinically significant) to Z -2.1 Stable weight about 115 Some hip and tibia pain with a normal bone scan in February Progressed to 50 miles per wk.
  44. 44. Senior Year 2006-2007 Maintained her wt well Running about 40 mi/wk November developed a left tibial stress fracture Now with right
  45. 45. 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
  46. 46. Female Athlete Triad OLD THEORY Disordered eating and/or excessive exercise → Low body weight and low body fat → Amenorrhea → Low estrogen → Decreased calcium absorption and utilization → Low bone density
  47. 47. Negative Energy Balance → Disruption of HPO axis Leptin polypeptide 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.
  48. 48. IMPROVING DETECTION OF Awareness in PPEs: Menstrual History History of Stress Fractures Calcium Intake and Vitamin D intake Frequent Follow-up: Labs and radiologic testing More extensive H & P: Mood, Stressors, Diet, Cardiac exam, Tanner stage, Hair growth
  49. 49. IMPROVING TREATMENT OF Medical/Nutritional/Psychiatric Teamwork Coach/Trainer/Athletic Department/Family support and awareness
  50. 50. 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
  51. 51. Thank You
  52. 52. Fitness: Environmental Risk Factor  Cardiovascular/Metabolic  Musculoskeletal – Strength – Flexibility – Endurance  Body Composition  Psychological
  53. 53. Head Injuries Post Concussive Syndrome Delayed response Distracted Disoriented Coordination issues Emotional lability Memory deficit Amnesia
  54. 54. Second Impact Syndrome SIS Occurs mostly in the adolescent 14-16 A second head injury(often minor) is sustained while still symptomatic from the first injury Altered cerebral autoregulation ⇒malignant brain edema Stable for 15 seconds to minutes ⇒precipitous collapse, comatose, respiratory failure Rapid intubation and osmotic diuresis(mannitol)
  55. 55. Cantu 1986American Academy of Neurology Grade I -No LOC, amnesia < 30 minutes Grade 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
  56. 56. 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)
  57. 57. 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
  58. 58. Return To Play Recommend injury grading in retrospect Symptom scores Question the significance of loss of consciousness Significance of amnesia Pediatric considerations
  59. 59. 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
  60. 60. Concussion Cases Nick soccer player Hannah hockey Player Gigi cheerleader
  61. 61. Upper Extremity Overuse Shoulder Syndromes Labal tears: popping Instability: subluxation or dead arm feeling Impingement: painful arch Biceps tendonitis: anterior pain AC joint: impingement
  62. 62. Upper Extremity Overuse Swimmers Shoulder Constellation of instability and impingement Training may require 10 to 15 thousand yards per day. 75% of this may be freestyle McMaster and Troup found shoulder pain in: 10% of age 13- 14 13% of age 15- 16 26% of elite college swimmers
  63. 63. Upper Extremity Overuse Swimmers Shoulder Inflammation in the supraspinatus and/or biceps tendons usually caused by glenohumeral instability Supraspinatus ischemia at the end of the pull phase
  64. 64. Upper Extremity Overuse Swimmers Shoulder Diagnosis History of pain at which part of the stroke Signs of impingement and instability Signs of rotator cuff weakness and inflexibility
  65. 65. Upper Extremity Overuse Swimmers Shoulder Treatment Relative rest but not deconditioned Some pool work Address rotator cuff stabilization
  66. 66. Upper Extremity Overuse Swimmers Shoulder Treatment Technique: 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
  67. 67. Upper Extremity Overuse Swimmers Shoulder Prevention 10% rule for increase in volume of time and intensity Weight train with attention to the rotator cuff Cross training
  68. 68. Make it or Break it

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