Influence of cold-water immersion on recovery of elite triathletes following the ironman world championship.

OBJECTIVES: Cold water immersion (CWI) has been widely used for enhancing athlete recovery though its use following an Ironman triathlon has never been examined. The purpose of this paper is to determine the influence of CWI immediately following an Ironman triathlon on markers of muscle damage, inflammation and muscle soreness. DESIGN: Prospective cohort study. METHODS: Thirty three (22 male, 11 female), triathletes participating in the Ironman World Championships volunteered to participate (mean±SD: age=40±11years; height=174.5±9.1cm; body mass=70±11.8kg; percent body fat=11.4±4.1%, finish time=11:03.00±01:25.08). Post race, participants were randomly assigned to a 10-min bout of 10°C CWI or no-intervention control group. Data collection occurred pre-intervention (PRE), post-intervention (POST), 16h (16POST) and 40h (40POST) following the race. Linear mixed model ANOVA with Bonferroni corrections were performed to examine group by time differences for delayed onset muscle soreness (DOMS), hydration indices, myoglobin, creatine kinase (CK), cortisol, C-reactive protein (CRP), IL-6 and percent body mass loss (%BML). Pearson's bivariate correlations were used for comparisons with finishing time. Alpha level was set a priori at 0.05. RESULTS: No significant group by time interactions occurred. Significant differences occurred for POST BML (-1.7±0.9kg) vs. 16POST, and 40POST BML (0.9±1.4, -0.1±1.2kg, respectively; p<0.001). Compared to PRE, myoglobin, CRP and CK remained significantly elevated at 40POST. Cortisol returned to PRE values by 16POST and IL-6 returned to PRE values by 40POST. CONCLUSION: A single bout of CWI did not provide any physiological benefit during recovery from a triathlon within 40h post race. Effect of CWI beyond this time is unknown.

Female adolescent athletes' attitudes and perspectives on injury prevention programs.

OBJECTIVES: To examine what factors influence a high school female athlete's stated willingness to perform a lower extremity injury prevention program (IPP). A secondary aim was to examine if a participant's stated willingness affected her compliance with an IPP. DESIGN: Repeated measures. METHODS: We surveyed high school female field hockey, soccer and volleyball athletes before and after a season-long IPP warm-up intervention. Participants completed the Injury Prevention Program Attitude Survey (IPPAS), a paper and pencil survey utilizing Likert-style and open-ended questions. It was used to assess the athletes' willingness to perform an IPP if the data proved the player would experience improved performance, fewer injuries and risk factors, what outside factors influence their willingness to perform an IPP, who they would feel comfortable leading their team in an IPP, and what they believe an IPP can improve. RESULTS: Participants responded that they were willing to perform an IPP if data proved that they would have fewer injury risk factors (p≤0.001) and be less likely to suffer an ACL injury (p<0.001). Improved sport performance did not play a role in participants' willingness to perform an IPP. Before and after the warm-up intervention, participants stated that stretching, strengthening, and cardiovascular activity should be included in an IPP. Participants' stated willingness and beliefs prior to the intervention did not appear to affect their compliance. CONCLUSIONS: Female adolescent athletes are willing to perform IPPs if data indicated that they would have fewer injury risk factors and suffer fewer ACL and leg injuries.

Implementing Health and Safety Policy Changes at the High School Level From a Leadership Perspective.

CONTEXT: Although consensus statements and recommendations from professional organizations aim to reduce the incidence of injury or sudden death in sport, nothing is mandated at the high school level. This allows states the freedom to create and implement individual policies. An example of a recommended policy is heat acclimatization. Despite its efficacy in reducing sudden death related to heat stroke, very few states follow the recommended guidelines. OBJECTIVE: To retroactively examine why and how 3 states were able to facilitate the successful creation and adoption of heat-acclimatization guidelines. DESIGN: Qualitative study. SETTING: High school athletic associations in Arkansas, Georgia, and New Jersey. PATIENTS OR OTHER PARTICIPANTS: Eight men and 3 women (n = 11; 6 athletic trainers; 2 members of high school athletic associations; 2 parents; 1 physician) participated. Participant recruitment ceased when data saturation was reached. DATA COLLECTION AND ANALYSIS: All phone interviews were digitally recorded and transcribed verbatim. A grounded-theory approach guided analysis and multiple analysts and peer review were used to establish credibility. RESULTS: Each state had a different catalyst to change (student-athlete death, empirical data, proactivity). Recommendations from national governing bodies guided the policy creation. Once the decision to implement change was made, the states displayed 2 similarities: shared leadership and open communication between medical professionals and members of the high school athletic association helped overcome barriers. CONCLUSIONS: The initiating factor that spurred the change varied, yet shared leadership and communication fundamentally allowed for successful adoption of the policy. Our participants were influenced by the recommendations from national governing bodies, which align with the institutional change theory. As more states begin to examine and improve their health and safety policies, this information could serve as a valuable resource for athletic trainers in other states and for future health and safety initiatives.

Comparison of Two Fluid Replacement Protocols During a 20-km Trail Running Race in the Heat.

Lopez, RM, Casa, DJ, Jensen, K, Stearns, RL, DeMartini, JK, Pagnotta, KD, Roti, MW, Armstrong, LE, and Maresh, CM. Comparison of two fluid replacement protocols during a 20-km trail running race in the heat. J Strength Cond Res 30(9): 2609-2616, 2016-Proper hydration is imperative for athletes striving for peak performance and safety, however, the effectiveness of various fluid replacement strategies in the field setting is unknown. The purpose of this study was to investigate how two hydration protocols affect physiological responses and performance during a 20-km trail running race. A randomized, counter-balanced, crossover design was used in a field setting (mean ± SD: WBGT 28.3 ± 1.9° C). Well-trained male (n = 8) and female (n = 5) runners (39 ± 14 years; 175 ± 9 cm; 67.5 ± 11.1 kg; 13.4 ± 4.6% BF) completed two 20-km trail races (5 × 4-km loop) with different water hydration protocols: (a) ad libitum (AL) consumption and (b) individualized rehydration (IR). Data were analyzed using repeated measures ANOVA. Paired t-tests compared pre-race-post-race measures. Main outcome variables were race time, heart rate (HR), gastrointestinal temperature (TGI), fluid consumed, percent body mass loss (BML), and urine osmolality (Uosm). Race times between groups were similar. There was a significant condition × time interaction (p = 0.048) for HR, but TGI was similar between conditions. Subjects replaced 30 ± 14% of their water losses in AL and 64 ± 16% of their losses in IR (p < 0.001). Ad libitum trial experienced greater BML (-2.6 ± 0.5%) compared with IR (-1.3 ± 0.5%; p < 0.001). Pre-race to post-race Uosm differences existed between AL (-273 ± 146 mOsm) and IR (-145 ± 215 mOsm, p = 0.032). In IR, runners drank twice as much fluid than AL during the 20-km race, leading to > 2% BML in AL. Ad libitum drinking resulted in 1.3% greater BML over the 20-km race, which resulted in no thermoregulatory or performance differences from IR.

Athletic Directors' Barriers to Hiring Athletic Trainers in High Schools.

CONTEXT: In its best-practices recommendation, the Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs urged all high schools to have a certified athletic trainer (AT) on staff. Despite the recommendation, many high schools lack the medical services of an AT. OBJECTIVE: To examine the barriers that athletic directors (ADs) face in hiring ATs in public high schools and in providing medical coverage for their student-athletes. DESIGN: Qualitative study. SETTING: Semistructured telephone interviews. PATIENTS OR OTHER PARTICIPANTS: Twenty full-time public high school ADs (17 men, 3 women) from various geographical regions of the United States (6 North, 4 South, 4 Midwest, 6 West) participated. Data saturation guided the total number of participants. DATA COLLECTION AND ANALYSIS: We completed telephone interviews guided by a semistructured questionnaire with all participants. Interviews were recorded and transcribed verbatim. Multiple-analyst triangulation and peer review were included as steps to establish data credibility. We analyzed the data using the principles of the general inductive approach. RESULTS: We identified 3 themes. Lack of power represented the inability of an AD to hire an AT, which was perceived to be a responsibility of the superintendent and school board. Budget concerns pertained to the funding allocated to specific resources within a school, which often did not include an AT. Nonbudget concerns represented rural locations without clinics or hospitals nearby; misconceptions about the role of an AT, which led to the belief that first-aid-trained coaches are appropriate medical providers; and community support from local clinics, hospitals, and volunteers. CONCLUSIONS: Many ADs would prefer to employ ATs in their schools; however, they perceive that they are bound by the hiring and budgeting decisions of superintendents and school boards. Public school systems are experiencing the consequences of national budget cuts and often do not have the freedom to hire ATs when other school staff are being laid off.

Athletic Directors' Barriers to Hiring Athletic Trainers in High Schools.

CONTEXT: In its best-practices recommendation, the Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs urged all high schools to have a certified athletic trainer (AT) on staff. Despite the recommendation, many high schools lack the medical services of an AT. OBJECTIVE: To examine the barriers that athletic directors (ADs) face in hiring ATs in public high schools and in providing medical coverage for their student-athletes. DESIGN: Qualitative study. SETTING: Semistructured telephone interviews. PATIENTS OR OTHER PARTICIPANTS: Twenty full-time public high school ADs (17 men, 3 women) from various geographical regions of the United States (6 North, 4 South, 4 Midwest, 6 West) participated. Data saturation guided the total number of participants. DATA COLLECTION AND ANALYSIS: We completed telephone interviews guided by a semistructured questionnaire with all participants. Interviews were recorded and transcribed verbatim. Multiple-analyst triangulation and peer review were included as steps to establish data credibility. We analyzed the data using the principles of the general inductive approach. RESULTS: We identified 3 themes. Lack of power represented the inability of an AD to hire an AT, which was perceived to be a responsibility of the superintendent and school board. Budget concerns pertained to the funding allocated to specific resources within a school, which often did not include an AT. Nonbudget concerns represented rural locations without clinics or hospitals nearby; misconceptions about the role of an AT, which led to the belief that first-aid-trained coaches are appropriate medical providers; and community support from local clinics, hospitals, and volunteers. CONCLUSIONS: Many ADs would prefer to employ ATs in their schools; however, they perceive that they are bound by the hiring and budgeting decisions of superintendents and school boards. Public school systems are experiencing the consequences of national budget cuts and often do not have the freedom to hire ATs when other school staff are being laid off.

Examining the influence of hydration status on physiological responses and running speed during trail running in the heat with controlled exercise intensity.

The purpose of this study was to determine the effects of dehydration at a controlled relative intensity on physiological responses and trail running speed. Using a randomized, controlled crossover design in a field setting, 14 male and female competitive, endurance runners aged 30 ± 10.4 years completed 2 (hydrated [HY] and dehydrated [DHY]) submaximal trail runs in a warm environment. For each trial, the subjects ran 3 laps (4 km per lap) on trails with 4-minute rests between laps. The DHY were fluid restricted 22 hours before the trial and during the run. The HY arrived euhydrated and were given water during rest breaks. The subjects ran at a moderate pace matched between trials by providing pacing feedback via heart rate (HR) throughout the second trial. Gastrointestinal temperature (T(GI)), HR, running time, and ratings of perceived exertion (RPE) were monitored. Percent body mass (BM) losses were significantly greater for DHY pretrial (-1.65 ± 1.34%) than for HY (-0.03 ± 1.28%; p < 0.001). Posttrial, DHY BM losses (-3.64 ± 1.33%) were higher than those for HY (-1.38 ± 1.43%; p < 0.001). A significant main effect of T(GI) (p = 0.009) was found with DHY having higher T(GI) postrun (DHY: 39.09 ± 0.45°C, HY: 38.71 ± 0.45°C; p = 0.030), 10 minutes post (DHY: 38.85 ± 0.48°C, HY: 38.46 ± 0.46°C; p = 0.009) and 30 minutes post (DHY: 38.18 ± 0.41°C, HY: 37.60 ± 0.25°C; p = 0.000). The DHY had slower run times after lap 2 (p = 0.019) and lap 3 (p = 0.025). The DHY subjects completed the 12-km run 99 seconds slower than the HY (p = 0.027) subjects did. The RPE in DHY was slightly higher than that in HY immediately postrun (p = 0.055). Controlling relative intensity in hypohydrated runners resulted in slower run times, greater perceived effort, and elevated T(GI), which is clinically meaningful for athletes using HR as a gauge for exercise effort and performance.

Assessing strategies to manage work and life balance of athletic trainers working in the National Collegiate Athletic Association Division I setting.

CONTEXT: Certified athletic trainers (ATs) working at the National Collegiate Athletic Association Division I level experience challenges balancing their professional and personal lives. However, an understanding of the strategies ATs use to promote a balance between their professional and personal lives is lacking. OBJECTIVE: To identify the strategies ATs employed in the Division I setting use to establish a balance between their professional and personal lives. DESIGN: Qualitative investigation using inductive content analysis. SETTING: Athletic trainers employed at Division I schools from 5 National Athletic Trainers' Association districts. PATIENTS OR OTHER PARTICIPANTS: A total of 28 (15 women, 13 men) ATs aged 35 ± 9 years volunteered for the study. DATA COLLECTION AND ANALYSIS: Asynchronous electronic interviews with follow-up phone interviews. Data were analyzed using inductive content analysis. Peer review, member checking, and data-source triangulation were conducted to establish trustworthiness. RESULTS: Three higher-order themes emerged from the analysis. The initial theme, antecedents of work-family conflict, focused on the demands of the profession, flexibility of work schedules, and staffing patterns as contributing to work-life conflict for this group of ATs. The other 2 emergent higher-order themes, professional factors and personal factors, describe the components of a balanced lifestyle. The second-order theme of constructing the professional factors included both organizational policies and individual strategies, whereas the second-order theme of personal factors was separation of work and life and a supportive personal network. CONCLUSIONS: Long work hours, lack of control over work schedules, and unbalanced athlete-to-AT ratios can facilitate conflicts. However, as demonstrated by our results, several organizational and personal strategies can be helpful in creating a balanced lifestyle.

Work-family conflict among athletic trainers in the secondary school setting.

CONTEXT: Work-family conflict (WFC) negatively affects a professional's ability to function at work or home. OBJECTIVE: To examine perceptions of and contributing factors to WFC among secondary school athletic trainers. DESIGN: Sequential explanatory mixed-methods study. SETTING: Secondary school. PATIENTS OR OTHER PARTICIPANTS: From a random sample of 1325 individuals selected from the National Athletic Trainers' Association Member Services database, 415 individuals (203 women, 212 men; age = 36.8 ± 9.3 years) provided usable online survey data. Fourteen individuals participated in follow-up interviews. INTERVENTION(S): Online WFC questionnaire followed by in-depth phone interviews. MAIN OUTCOME MEASURE(S): Descriptive statistics were obtained to examine perceived WFC. Pearson product moment correlations were calculated to examine the relationship between work hours, total athletic training staff, and number of children and WFC score. We performed analysis of variance to examine differences between the independent variables of sex and control over work schedule and the dependent variable of WFC score. The a priori α was set at P ≤ .05. Qualitative data were analyzed using inductive content analysis. Multiple-analyst triangulation and member checks established trustworthiness of the qualitative data. RESULTS: Mean WFC scores were 23.97 ± 7.78 for scale 1 (family defined as having a partner or spouse with or without children) and 23.17 ± 7.69 for scale 2 (family defined as individuals, including parents, siblings, grandparents, and any other close relatives, involved in one's life), indicating moderate perceived WFC. A significant relationship was found between the average hours of work per week and WFC scores: those with less scheduling control experienced more WFC. Two dimensions emerged from the qualitative methods that relate to how WFC is mitigated in the secondary school environment: (1) organizational-having colleagues and administration that understood the role demands and allowed for modifications in schedule and personal time and (2) personal-taking time for oneself and having a family that understands the work demands of an athletic trainer resulted in reduced perceived WFC. CONCLUSIONS: A large number of work hours per week and lack of control over work schedules affected the perceived level of WFC.

Evidence-based medicine and the recognition and treatment of exertional heat stroke, part II: a perspective from the clinical athletic trainer.

CONTEXT: Exertional heat stroke (EHS) is one of the leading causes of death in athletes. Certified athletic trainers (ATs) demonstrate strong knowledge of recommended practices with EHS but are apprehensive in implementing 2 basic procedures: rectal temperature assessment and cold water immersion. This apprehension might lead to deaths from EHS that could have been prevented. OBJECTIVE: To investigate why collegiate and high school ATs do not implement best practices for the recognition and treatment of EHS. DESIGN: Qualitative study. SETTING: In-person focus groups consisting of 3 to 6 collegiate or high school ATs. PATIENTS OR OTHER PARTICIPANTS: A total of 19 ATs (9 men, 10 women; age = 36 ± 10 years, length of certification = 12 ± 9 years) employed at either the collegiate (n = 10) or high school (n = 9) level participated in the study. DATA COLLECTION AND ANALYSIS: Interviews were transcribed verbatim, and data were analyzed using deductive data analysis. Peer review and multiple-analyst data triangulation were conducted to establish trustworthiness of the data. RESULTS: Five emergent themes explained the lack of evidence-based practice (EBP) regarding recognition and treatment of EHS. Three themes (lack of knowledge, comfort level, lack of initiative) were common in both the collegiate and high school settings, and 2 separate themes (liability concerns, lack of resources) were present in the high school setting. CONCLUSIONS: Our findings are consistent with those in the literature on EBP and EHS. Regardless of clinical setting, ATs have basic information on recognition and treatment of EHS, but 5 themes act as barriers to implementing proper management in the clinical setting. Workshops or hands-on training sessions need to be made available to improve students' comfort levels so ATs will implement EBP into everyday settings.

Evidence-based practice and the recognition and treatment of exertional heat stroke, part I: a perspective from the athletic training educator.

CONTEXT: Athletic trainers (ATs) know to diagnose exertional heat stroke (EHS) via rectal thermometry (T(re)) and to treat EHS via cold-water immersion (CWI) but do not implement these recommendations in clinical practice. OBJECTIVE: To gain an understanding of educational techniques used to deliver content regarding EHS. DESIGN: Qualitative study. SETTING: In-person focus groups at the National Athletic Trainers' Association (NATA) Annual Meeting in June 2009 and 2 follow-up telephone interviews to confirm emergent themes. PATIENTS OR OTHER PARTICIPANTS: Thirteen AT educators (11 men, 2 women) from programs accredited by the Commission on Accreditation of Athletic Training Education, with an average of 22 ± 9 years of clinical experience and 16 ± 10 years of experience as educators. Five NATA districts were represented. DATA COLLECTION AND ANALYSIS: Data were analyzed using inductive content analysis. Peer review and data source triangulation also were conducted to establish trustworthiness. RESULTS: Four themes emerged from the analysis: educational techniques, educational competencies, previous educational training, and privacy/public opinion. Educational techniques highlighted the lack of hands-on training for T(re) and CWI. Educational competencies referred to the omission of T(re) and CWI as psychomotor skills. Previous educational training addressed educators not having the skills or comfort with the skills necessary to properly educate students. Privacy/public opinion comprised external inputs from various groups (parents and coaches), legal considerations, and social bias. CONCLUSIONS: Educators supplied students with the appropriate didactic knowledge about EHS, but their lack of training and misgivings about T(re) prevented them from allowing students to gain competence with this skill. Until the NATA competencies state the need to teach T(re) and CWI and until educators are provided with their own learning opportunities, evidence-based practice regarding EHS will be lacking.