Issue 24 Spring 2018
The official magazine of the Football Medical Association
In this issue: Anxiety & Getting Injured Cryotherapy Exposure Durations Antioxidant Supplements Context is King; Interpreting Match Performance
Exclusive:
Football Rehabilitation How to safely reintegrate, avoid re-injury and prepare players for the demands of the Premier League
FMA FOOTBALL MEDICAL ASSOCIATION
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Contents Welcome 4
Members’ News
Features 6
Football rehabilitation: How to safely reintegrate, avoid re-injury and prepare players for the demands of the Premier League Damian Roden
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Women’s football and the menstrual cycle... how we can further individualise? Andrew Wiseman & Georgie Bruinvels
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FMA Conference & Awards 2018
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Grass to game Scott Pearce
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Why screening ‘mental health’ might be the missing link in reducing injury Andy Barker
CHIEF EXECUTIVE OFFICER
A
s an educational platform we once again look to our colleagues working in the sporting arena to relate their own experiences within the scope of the Conference title, which this year is ‘Development and Innovation in Sports Performance and Medicine’. The title deliberately allows scope for a wide variety of discussion points and ideas and what can be better than learning and identifying with fellow practitioners. As a networking experience the event is second to none, as this piece of feedback received last year from Lincoln City Football Club’s Head of Sports Science, Mike Hine, testifies: “The conference was fantastic for our department last summer. We spent the Saturday night on a table with Middlesbrough’s staff discussing all things medical and sports science. Where else could you bring together two groups that in the previous season had been working in the top tier and the fifth tier?
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Don’t waste your time taking antioxidant supplements after exercise Mayur Ranchordas
“The networking element that we took from the event was brilliant. Several offers from superior club staff to visit their training grounds and get an insight into their work was remarkable. I personally have contacted a number of the people I met that weekend in order to seek advice or guidance on certain things this season.”
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The effect of three different (-135°C) whole body cryotherapy exposure durations on elite rugby league players Jill Alexander
With the Conference also serving as an awards event, we continue to recognise the tireless endeavours of our members. We have already had four-times more nominations sent through than last year for various categories within the awards programme; a clear indication of the value in which these awards are now held.
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‘Context is king’ when interpreting match physical performances Paul S Bradley, Mark Evans, Andy Laws & Jack D Ade
With an exceptional event management team now in place, state-of-the-art AV system and a well-known host conducting the awards, the entire event now demonstrates exactly where we are. Enjoy this issue of Football Medic and Scientist. I look forward to seeing you at this year’s Conference.
Eamonn Salmon
CEO Football Medical Association Football Medical Association, 6A Cromwell Terrace, Gisburn Road, Barrowford, Lancashire, BB9 8PT T: 0333 456 7897 E: info@footballmedic.co.uk W: www.footballmedic.co.uk
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Eamonn Salmon Eamonn@footballmedic.co.uk
Executive Administrator Lindsay Butler Lindsay@footballmedic.co.uk
COVER IMAGE Southampton’s Charlie Austin limps off injured during the Premier League match at St Mary’s. Adam Davy/PA Images Football Medical Association. All rights reserved. The views and opinions of contributors expressed in Football Medic & Scientist are their own and not necessarily of the FMA Members, FMA employees or of the association. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a retrieval system without prior permission except as permitted under the Copyright Designs Patents Act 1988. Application for permission for use of copyright material shall be made to FMA. For permissions contact admin@footballmedic.co.uk.
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THE EFFECT OF THREE DIFFERENT (-135°C) WHOLE BODY CRYOTHERAPY EXPOSURE DURATIONS ON ELITE RUGBY LEAGUE PLAYERS FEATURE/JILL ALEXANDER The aim of the study was to explore whether the length of whole body cryotherapy (WBC) exposures affect changes in inflammatory blood markers, tissue oxygenation, core and skin surface temperature alongside thermal comfort and sensation. The application of extreme cold air for short periods known as WBC presents anecdotal evidence for its use in elite sport, with minimal evidence to identify optimal exposure protocols. Methods: Fourteen elite male rugby super league players exposed to 1, 2 and 3 minutes of WBC at -135°C. The study was a randomised cross over design, participants acted as their own control with testing for each exposure separated by seven days, taking place the day following a competitive league fixture. Results: Significant reductions in skin surface temperature, thermal comfort and thermal sensation were noted (P=<.05) but no significant change in core temperature (P>.05). No significant changes recorded for inflammatory blood markers (IL-6). Results further reported significant reductions in deoxyhaemoglobin for gastrocnemius and vastus lateralis. Significant reductions in oxyhaemoglobin and tissue oxygenation index were also demonstrated (P=<.05). Conclusion: A 2-minute WBC exposure was the optimum exposure length at temperatures of -135°C, however physiological changes in Il-6 or core temperature were unaffected following three brief exposures of WBC separated by 1 week. Although significant changes in skin surface temperature, thermal sensation, deoxyhaemoglobin, oxyhaemoglobin, and tissue oxygenation index occurred. Introduction: Prevalent for its use amongst the elite sporting populations, reportedly WBC promotes recovery and prevention of injury via therapeutic application of extreme cold air (-110°C-140°C). Physiological effects of WBC discussed in current literature, fail to present optimal protocols specifically around exposure duration, with typical exposures varying between 2-3 minutes. Therefore, it is ambiguous as to what WBC protocol is required to initiate beneficial physiological changes to support recovery or for the prevention of injury. A common change reported following WBC exposures is the reduction in inflammatory markers (Banfi et al, 2010; Lubrowska et al, 2010; Wozniak et al, 2007). Hausswirth et al (2011) identified
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the acceleration of exercise induced muscle damage (EIMD) following multiple WBC exposures, although Costello and colleagues (2012) reported poor results in trying to alleviate EIMD and soreness with WBC. It is difficult to compare physiological changes across available studies due to differences in methodologies and inconsistencies that may occur across sporting populations. WBC research reports commonly in rugby populations, due to the physical demands of the sport, anecdotally WBC is regularly used in elite football, although limited research is available to support optimum protocols in that specific athletic population. Methods Participants A single group randomised cross over design included fourteen volunteer professional rugby super league players (24 years; height 183.2cm; weight 77.6 kg) from a professional super rugby league club. Data was collected mid-competitive season, all participants were uninjured, training fully and took part in a competitive fixture the day prior to testing. All participants completed health-screening checks and provided written informed consent to take part in the study. Testing Procedure Separated by seven days, three different WBC exposures followed a competitive fixture the previous evening. Each participant acted as their own control and randomly allocated to exposure lengths of 1, 2, or 3 minutes. The exposure protocol consisted of 30 second precooling at -60°C, followed by the random exposure (1, 2 or 3 minutes) at -135°C in a liquid nitrogen cryochamber (JUKA, Poland), owned and operated by BOC Linde. Baseline testing included venous blood samples (three days prior to the first WBC exposure) with pre-cooling measurements taken for venous blood samples (S-Monovette blood collection system
(Starstedt)), muscle oxygenation levels (Near-infrared spectrometer (NIRO-200 Oxygenation Monitor, Hamamatsu, Japan)), skin surface temperature (ThermoVision, A40M Thermal imaging Camera (Flir Systems, Danderyd, Sweden)), core temperature (CorTemp® Wireless Ingestible temperature Sensor-Product No. HT150002. HQInc. Florida. USA) and thermal comfort/ sensation (Chloewka et al, 2012). Following exposure, the same data were collected immediately and up to 20 minutes post WBC exposure over 5 minute increments. Statistical Analysis: A mixed methods model (SPSS version 19.0, SPSS Inc, Chicago, IL, USA) analysed continuous data using preexposure data as a covariate, this determined changes between pre and all other timepoints. Fixed factors were time points and exposure. The data were assessed and found to be suitable for parametric statistical testing. To explore differences between the three exposures, nominal questionnaire data were analysed using a Friedman Test, with a Wilcoxon sign rank test used as a post-hoc analysis to compare exposure and time point differences. Results: Comparison of all parameters between time points, pre, immediately post, +5, +10, +15 and +20 minutes post WBC exposures, for each exposure (1, 2, and 3 minutes) are demonstrated in table 1. A comparison between WBC exposure times for all testing parameters and significant values are representable in Table 2. Significant reductions in skin surface temperature, thermal comfort and thermal sensation were noted (P=<.05) but no significant change in core temperature (P>.05) following WBC exposures. No significant changes recorded for inflammatory blood markers (IL-6). Results further reported significant reductions in deoxyhaemoglobin for gastrocnemius and vastus lateralis. Significant reductions in oxyhaemoglobin and tissue oxygenation index were also demonstrated (P=<.05).
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football medic & scientist Table 1. Comparison of parameters between time points, pre, immediately post, +5, +10, +15 and +20 minutes post WBC exposures for all exposures. Time Point*
to Time Point
Core Temp 째C**
Sig.
Tsk 째C***
Sig.
0
1
-0.5
0.21
8.85
0
4.28
0
2
3.4
0
-2.15
0
3
2.59
0
-1.62
0
4
0
5
1
2
-0.38
0.35
2.19
0
2.01
0
-5.45
0
Blood IL-6
Sig.
0.15
NIRO G O2HB
Sig.
NIRO G HHB
Sig.
NIRO G TOI
Sig.
NIRO VL Sig. O2HB
NIRO VL HHB
Sig.
0.31
12.79
0.03
2.36
0.11
-1.7
0.61
-3.05
0.6
1.78
0.23
-3.74
0.7
-7.83
0.18
1.19
0.42
-1.8
2.33
0.58
-6.52
0.27
0.95
0.52
-6.43
0.13
-15.85
0.01
-0.58
0.69
NIRO VL Sig. TOI
0.6
6.85
0.04
3.81
0.25
-0.43
0.9
2.2
0.21
0.58
-2.59
0.44
2.44
0.16
-1.18
0.71
1.24
0.71
1.54
0.38
-2.04
0.53
-7.28
0.03
-1.61
0.35
0.03
0.91
1
3
-6.26
0
-5.9
0.16
-20.62
0
-1.17
0.43
-0.1
0.98
-9.44
0.01
-1.38
0.43
1
4
-6.66
0
-1.95
0.64
-19.31
0
-1.41
0.34
0.52
0.87
-5.61
0.1
-2.28
0.19
1
5
-6.84
0
2
3
0.12
0.76
-0.81
0
0.53
0.9
-4.77
0.41
-0.59
0.69
1.95
0.55
-2.16
0.52
0.24
0.89
2
4
-1.21
0
4.49
0.29
-3.46
0.55
-0.83
0.57
2.56
0.43
1.67
0.62
-0.66
0.7
2
5
-1.39
0
3
4
-0.4
0.09
3.96
0.35
1.31
0.82
-0.24
0.87
0.61
0.85
3.83
0.26
-0.9
0.6
3
5
-0.58
0.02
4
5
-0.18
0.46
Table 2. Comparison between WBC exposure times for all testing parameters and significant values Measurement
WBC Exposure Time (minutes)
Compared to WBC exposure time (minutes)
Mean Difference
Sig.
Interleukin Six (IL-6) (pg/mL)
1
2
0.37
0.81
1
3
0.14
0.93
2
3
-0.23
0.89
1
2
-2.5
0.58
1
3
-0.41
0.93
2
3
2.09
0.64
1
2
-0.87
0.45
1
3
-1.98
0.08
2
3
-1.11
0.33
1
2
2.24
0.37
1
3
5.93
0.02
2
3
3.7
0.14
1
2
-3.82
0.14
1
3
-2.53
0.33
2
3
1.29
0.62
1
2
-0.28
0.84
1
3
1.78
0.19
2
3
2.06
0.13
1
2
1.21
0
1
3
1.7
0
2
3
0.5
0
1
2
0.51
0.2
1
3
0.72
0.08
2
3
0.2
0.62
Tsk (째C)**
Core Temperature (째C)*
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Discussion: The results of the study reports 30 seconds at -60°C followed by 2 minutes WBC at around -135°C appear to be an optimum WBC exposure time. A 2-minute WBC exposure produces physiological changes in core and skin temperature, tissue oxygenation in vastus lateralis and gastrocnemius muscles and thermal sensation responses. To the authors knowledge no other study has examined duration of WBC exposure time and the effects on the multiple observation of tissue oxygenation, core temperature, skin surface temperature, inflammatory marker (IL-6), thermal comfort or sensation in elite athletic populations
the antecubital fossa. Vascular shunting took place from upper to lower limbs following a 3-minute WBC exposure. In summary, although venepuncture was successful, the level of blood flow often appeared compromised, and more commonly, this occurred following the 3-minute WBC exposure.
The current study revealed increases in Il-6, 10-16 hours post-competitive fixture, in line with previous research (Pedersen, 2011). Variance in IL-6 levels were noticed by the high standard deviations reported, but thought to be due to the variance in playing positions causing differences in player movement/loading during play. Future studies should consider the positional differences and consider that this may occur across other sports, such as football. Irrespective of WBC duration, the current study reports that a single bout of WBC does not alter IL-6 levels, supporting a previous study by Pournot et al (2011) observing 3 minute exposures at -110°C. Compared to other studies (Fonda, 2013; Hausswirth et al, 2011; Lubkowska et al, 2011), our collection of blood samples at 20 minutes post WBC exposure was the shortest time period reported, therefore it may have been too early to detect changes in inflammatory markers. The collection of venous blood samples following a 3-minute WBC exposure posed challenges in the partial ‘shut down’ of peripheral vasculature of the median vein of
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Tissue oxygenation significantly differed after a 3-minute WBC exposure compared to 1 or 2 minute exposures. The results suggest localised tissue hypoxia in the vastus lateralis muscle. A decrease in blood volume in the gastrocnemius muscle also reported at 0-5 minutes post WBC. Indicative of venous pooling, oxyhaemoglobin and deoxyhaemoglobin both increased to above pre-WBC measures over the remaining 15 minute time-period. Perhaps due to a weaker vasoconstriction response rather than active vasodilation, results suggest gastrocnemius compared to vastus lateralis is more susceptible to pooling. It is common to observe vasoconstriction of peripheral blood vessels under moderately cold temperatures in order to maintain core temperature (Stocks et al, 2004). The present study demonstrates physiological responses, but under extreme cold exposure, the body aims to protect the extremities, with cold-induced vasodilation (CIVD) occurring (Reynolds et al, 2007). Deeper musculature loses heat to the surface initiating CIVD response. Although exact mechanisms are not fully understood, in line with previous research we note that core temperature rose above 36°C immediately post 3-minute WBC exposure, along with peripheral blood volume/flow increases and pooling; in response to these processes, therefore the concept of CIVD may be supported.
WBC exposure demonstrated effective reductions is skin surface temperature in agreement with previous studies (Cholewka et al, 2012). Although core temperature did not present any significant changes this supports the predictable relationship with skin surface temperature cooling. Where the lowest post WBC reduction in skin temperature occurred, core temperature demonstrated a rise. Observed across all exposure times this supports the observation of vascular shunting to maintain normal functions of vital organs during exposure to extreme cold. Recordings of thermal sensation and comfort from participants demonstrated no differences in 2-3 minutes of WBC exposure, but significant differences in sensation were reported when comparing 1-2 minute exposures. Perceptions in temperature sensation suggest that 1-minute WBC exposures may not be long enough to note changes in sensation of cold. Practical Implications: Professions working within elite sport may advise that applying an optimal WBC exposure time of 2 minutes at around -135°C physiological changes may occur; however, it would be useful to apply this protocol in different sports such as football. Clinicians should utilise the protocol from this study to compare future research that will help now determine the number of required WBC exposure sessions to initiate larger physiological responses. The findings from future studies may be welcomed to direct optimum protocols for use in elite football populations in order to aid recovery or as a preventative injury measure. Research investigating WBC on other elite athletes and women would be advantageous to broaden the knowledge on WBC across a variety of sports and gender.
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football medic & scientist Full paper reference: Selfe, J., Alexander, J., Costello, JT., May, K., Garratt, N., Atkins, S., Dillon, S., Hurst, H., Davison, M., Przybyla, D., Coley, A., Bitcon, M., Littler, G., Richards, J. (2014). The Effect of Three Different (-135°C) Whole Body Cryotherapy Exposure Durations on Elite Rugby League Players. PLoS ONE 9(1); 1-9. References Costello JT, Algar L and Donnelly A. (2012) Effects of whole-body cryotherapy (-110C) on proprioception and indices of muscle damage. Scand J Med Sci Sports, 22:190-198. Cholewka, A., Drzazga, Z., and Sieron, A. (2012). Thermography study of skin response due to whole-body cryotherapy. Skin Res Technol, 18:180187. Banfi G, Lombardi G, Columbini A, et al. (2010) Whole-body cryotherapy in athletes. Sports Med, 7:1-9. Fonda, B and Sarabon, N. (2013). Effects of whole-body cryotherapy on recovery after hamstring damaging exercise: A crossover study. Scand J Med Sci Sports, 23:270-278. Lubkowska A, Banfi G, Dolegowska B, et al. (2010) Changes in lipid profile in response to three different protocols of whole-body cryostimulation treatments. Cryobiology, 61:22-25. Hausswirth C, Louis J, Bieuzen F, et al. (2011) Effects of whole-body cryotherapy vs. far-infrared vs. passive modalities on recovery from exerciseinduced muscle damage in highly-trained runners. PLoS ONE, 12:1-7. Pedersen BK and Febbraio MA. (2008). Muscle as an endocrine organ: focus on muscle-derived interleukin-6. Physiol. Rev, 88:1379-1406. Pournot H, Bieuzen F, Louis J, et al. (2011). Time-course of changes in inflammatory responses after whole-body cryotherapy multi exposures following severe exercise. PLos ONE, 6:1-6. Reynolds, J.D., Ahearn, G.S., Angelo, M., Zhang, J., Cobb, F., et al. (2007). S-nitrosohemoglobin deficiency: A mechanism for loss of physiological activity in banked blood. PNAS, 104:17058-17062. Stocks JM, Taylor NAS, Tipton MJ, et al. (2004). Human physiological responses to cold exposure. Aviation Space Environ Med, 75:444-457. Wozniak A, Wozniak B, Drewa G, et al. (2007). The effect of whole-body cryostimulation on lysosomal enzyme activity in kayakers during training, 100:137-142.
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