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