Dietary habits in adolescent male and female handball players: the Swedish Handball Cohort.

Objectives: This cross-sectional study aimed to describe dietary habits in Swedish adolescent handball players and differences with respect to sex and school grade. Methods: Participants in the Swedish Handball Cohort answered a web-survey assessing adherence to sports nutrition recommendations for meal frequency and meal timing, and the Nordic Nutrition Recommendations (NNR) for fruits/vegetables and fish/seafood, food exclusions and use of dietary supplements. Differences with respect to sex and school grade were estimated with generalised linear models, generating prevalence ratios (PR) with 95% CIs. Results: A total of 1040 participants (16.6±0.9 years, 51% males) were included. Overall, 70% and 90%, respectively, met recommendations for meal frequency and meal timing, whereas adherence to recommended carbohydrate intake during training/game was met by 17%. Adherence to the NNR for fruits/vegetables and fish/seafood was met by 16% and 37%, respectively. Twenty-eight per cent reported using dietary supplements. Females reported lower frequency of meals, especially morning snacks (-0.6 days/week (95% CI -0.3 to -0.9)) and evening snacks (-0.8 days/week (95% CI -0.5 to -1.1)), higher prevalence of exclusions due to intolerances (PR 1.66 (95% CI 1.31 to 2.01)) and other reasons (PR 1.36 (95% CI 1.08 to 1.64)), higher adherence to the NNR for fruits/vegetables (PR 2.30 (95% CI 1.98 to 2.62)) and use of micronutrient supplements (PR 1.72 (95% CI 1.43 to 2.00)) compared with males. Only small differences were observed between school grades. Conclusions: Swedish adolescent handball players' dietary habits are fairly in accordance with sports nutrition recommendations but not the NNR. Females appear to display more restrictive habits than males.

Lifestyle characteristics in adolescent female football players: data from the Karolinska football Injury Cohort.

BACKGROUND: Normative values of lifestyle characteristics in adolescent female football players may be used by clinicians and coaches to take actions because the potential important for well-being, performance on the pitch, and risk of injury. The aim was to report descriptive characteristics of lifestyle factors in adolescent female football players and potential changes over 1 year. METHODS: We included 419 adolescent competitive female football players from 12 clubs and 27 teams (age 14 ± 1 years, range 12-17 years) and 286 were followed over 1 year. The players completed an extensive questionnaire regarding demographics, football-related factors, and lifestyle factors including tobacco consumption, alcohol use, medicine intake, eating and sleeping habits, well-being, stress, coping, and passion. Baseline data are presented for the total cohort and separately for 4 age groups (12, 13, 14, and 15-17 years). RESULTS: 12% skipped breakfast, 8% skipped lunch and 11% used protein supplements several days per week. 16% slept less than 8 h/night, 8% had impaired sleep with daytime consequences, and 22% stated that they were tired in daily activities several days per week. 32% experienced stress some or most days/week and 24% were classified as having psychological distress. Medicine intake (23% vs. 34%), skipping breakfast or lunch several days per week (10% vs. 47% and 20 vs. 33%), tiredness (20% vs. 27%), stress (26% vs. 40%), and psychological distress (27% vs. 37%) increased significantly (P = 0.031 to < 0.001) at the 1-year follow-up. CONCLUSION: Many adolescent female football players skip breakfast and lunch, have insufficient sleep, experience stress and are classified as having psychological distress. These factors increased over 1 year.

Normative values and changes in range of motion, strength, and functional performance over 1 year in adolescent female football players: Data from 418 players in the Karolinska football Injury Cohort study.

OBJECTIVE: To study normative values of range of motion (ROM), strength, and functional performance and investigate changes over 1 year in adolescent female football players. DESIGN: Cross-sectional. PARTICIPANTS: 418 adolescent female football players aged 12-17 years. MAIN OUTCOME MEASURES: The physical characteristic assessments included (1) ROM assessment of the trunk, hips, and ankles; (2) strength measures (maximal isometric and eccentric strength for the trunk, hips, and knees, and strength endurance for the neck, back, trunk and calves), and (3) functional performance (the one-leg long box jump test and the square hop test). RESULTS: Older players were stronger, but not when normalized to body weight. Only small differences in ROM regarding age were found. ROM increased over 1 year in most measurements with the largest change in hip external rotation, which increased by 6-7° (Cohen's d = 0.83-0.87). Hip (d = 0.28-1.07) and knee (d = 0.38-0.53) muscle strength and the square hop test (d = 0.71-0.99) improved over 1 year. CONCLUSIONS: Normative values for ROM and strength assessments of neck, back, trunk, hips, knees, calves and ankles are presented for adolescent female football players. Generally, fluctuations in ROM were small with little clinical meaning, whereas strength improved over 1 year.

Athletic Identity and Shoulder Overuse Injury in Competitive Adolescent Tennis Players: The Smash Cohort Study.

Objectives: Our primary aim was to determine if athletic identity is prospectively associated with shoulder overuse injuries. Secondly, we aimed to determine if athletic identity is prospectively associated with playing through pain and to describe how athletic identity relates to sex, age, playing level, weekly training load, and match volume. Methods: A cohort of 269 adolescent tennis players were followed over a period of 52 weeks. Cox regression was used to estimate the hazard rate ratio (HRR) of first-time shoulder overuse injury associated with every 10-unit increase on the Athletic Identity Measurement Scale (AIMS). Results: The adjusted HRR of shoulder overuse injury was 0.89 (95% CI: 0.36-2.20) and the odds ratio of playing through pain was 2.41 (95% CI: 0.74-8.96) for every 10 unit increase on AIMS. The level of athletic identity was higher among players at the national level than among players at the regional level and was weakly correlated to weekly hours of tennis matches, tennis training, and fitness training. Conclusions: Our results indicate that higher levels of athletic identity may be associated with a lower incidence of shoulder overuse injuries, and potentially with playing through pain, although these results are inconclusive due to wide confidence intervals.

The Effect of Shoulder and Knee Exercise Programmes on the Risk of Shoulder and Knee Injuries in Adolescent Elite Handball Players: A Three-Armed Cluster Randomised Controlled Trial.

BACKGROUND: The risk of injury in adolescent handball is high, and shoulder and knee injuries are among the most frequent and burdensome. The Swedish Knee Control programme reduced the risk of anterior cruciate ligament injuries in female youth football players and traumatic knee injuries in male and female youth floorball players. However, to date, Knee Control has not been evaluated in an elite youth sport setting. The literature on the prevention of shoulder injuries in sport is scarce, and there are to our knowledge no previous studies evaluating the preventative efficacy of injury prevention exercise programmes (IPEPs) on shoulder injuries in adolescent handball players. OBJECTIVES: To study the preventive efficacy of IPEPs on shoulder and knee injuries in adolescent elite handball players. METHODS: Eighteen Swedish handball-profiled secondary schools (clusters) with players aged 15-19 years, 54% males were randomised into either the Shoulder Group or Knee Group (interventions) or a Control Group. Players in the Shoulder Group were instructed to perform the Shoulder Control programme, and  players in the Knee Group to perform the Knee Control programme, three times per week during May 2018 to May 2019. Control Group players continued their usual training. Outcomes were shoulder and knee injuries defined by the Oslo Sports Trauma Research Center Overuse Injury Questionnaire. Intention-to-treat analyses were performed using Cox regression models with hazard rate ratios (HRRs) with corresponding 95% confidence intervals (CI). RESULTS: Six clusters (199 players) in the Shoulder Group, six clusters (216 players) in the Knee Group and six clusters (212 players) in the Control Group were included. There were 100 shoulder injuries and 156 knee injuries. The Shoulder Group had a 56% lower shoulder injury rate, HRR 0.44 (95% CI 0.29 to 0.68), and the Knee Group had a 31% lower knee injury rate, HRR 0.69 (95% CI 0.49 to 0.97) than the Control Group. The absolute risk reduction was 11% and 8%, and the number needed to treat was 9 and 13, respectively. CONCLUSIONS: Adolescent elite handball players who performed the Shoulder Control and the Knee Control programmes had a lower risk of shoulder and knee injuries, respectively, than players who continued their usual training. Further research on how these two programmes can be combined to reduce knee and shoulder injuries in a time effective way is warranted. Trial registration ISRCTN15946352. Key points The burden of knee and shoulder injuries in handball is high. The Shoulder Control programme reduces the risk and overall burden of shoulder injuries in adolescent elite handball players. The Knee Control programme reduces the risk and overall burden of knee injuries in adolescent elite handball players.

Eccentric and Isometric Shoulder Rotation Strength and Range of Motion: Normative Values for Adolescent Competitive Tennis Players.

The aim of this cross-sectional study was to investigate isometric internal rotation (IR), external rotation (ER), abduction (ABD), and eccentric external rotation (eccER) shoulder strength and rotational range of motion (ROM) in adolescent male and female competitive tennis players. Additional aims of the study were to provide a tennis-specific normative database based on a large sample of players to deepen the knowledge regarding shoulder strength and ROM for adolescent competitive tennis players, and to discuss differences based on sex, age, and level of play. Shoulder strength and ROM was assessed in 301 adolescent competitive tennis players, 176 boys and 125 girls with a mean age of 14.6 and 14.4 years, respectively. Outcome variables of interest were isometric IR and ER strength, ABD strength, eccER shoulder strength, intermuscular strength ratios ER/IR and eccER/IR, IR ROM, ER ROM, and total range of motion (TROM). A General Linear Model two-way ANOVA was used to analyze differences in sex, age, and level of play. The findings of this study demonstrated age, side, and sex differences in the shoulder isometric strength, the eccER strength and ROM in adolescent competitive tennis players. Furthermore, when strength was expressed as ratios ER/IR and eccER/IR both sexes showed a lower ratio for eccER/IR in national players (0.95 ± 0.22 and 0.95 ± 0.23) compared to regional players (1.01 ± 0.32 and 1.07 ± 0.29) for male and female players, respectively. In conclusion, this paper presents a tennis-specific normative database for shoulder rotation strength and ROM in adolescent male and female competitive players. The key points in this evaluation are strength values normalized to body mass, intermuscular ratios, and TROM.

Study protocol for a prospective cohort study identifying risk factors for sport injury in adolescent female football players: the Karolinska football Injury Cohort (KIC).

INTRODUCTION: Football is a popular sport among young females worldwide, but studies concerning injuries in female players are scarce compared with male players. The aim of this study is to identify risk factors for injury in adolescent female football players. METHODS AND ANALYSIS: The Karolinska football Injury Cohort (KIC) is an ongoing longitudinal study that will include approximately 400 female football academy players 12-19 years old in Sweden. A detailed questionnaire regarding demographics, health status, lifestyle, stress, socioeconomic factors, psychosocial factors and various football-related factors are completed at baseline and after 1 year. Clinical tests measuring strength, mobility, neuromuscular control of the lower extremity, trunk and neck are carried out at baseline. Players are followed prospectively with weekly emails regarding exposure to football and other physical activity, health issues (such as stress, recovery, etc), pain, performance and injuries via the Oslo Sports Trauma Research Center Overuse Injury Questionnaire (OSTRC-O). Players who report a substantial injury in the OSTRC-O, that is, not being able to participate in football activities, or have reduced their training volume performance to a moderate or major degree, are contacted for full injury documentation. In addition to player data, academy coaches also complete a baseline questionnaire regarding coach experience and education. ETHICS AND DISSEMINATION: The study was approved by the Regional Ethical Review Authority at Karolinska Institutet, Stockholm, Sweden (2016/1251-31/4). All participating players and their legal guardians give their written informed consent. The study will be reported in accordance with the Strengthening the Reporting of Observational studies in Epidemiology. The results will be published in peer-reviewed academic journals and disseminated to the Swedish football movement through stakeholders and media.

2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels.

SYNOPSIS: There is an absence of high-quality evidence to support rehabilitation and return-to-sport decisions following shoulder injuries in athletes. The Athlete Shoulder Consensus Group was convened to lead a consensus process that aimed to produce best-practice guidance for clinicians, athletes, and coaches for managing shoulder injuries in sport. We developed the consensus via a 2-round Delphi process (involving more than 40 content and methods experts) and an in-person meeting. This consensus statement provides guidance with respect to load and risk management, supporting athlete shoulder rehabilitation, and decision making during the return-to-sport process. This statement is designed to offer clinicians the flexibility to apply principle-based approaches to managing the return-to-sport process within a variety of sporting backgrounds. The principles and consensus of experts working across multiple sports may provide a template for developing additional sport-specific guidance in the future. J Orthop Sports Phys Ther 2022;52(1):11-28. doi:10.2519/jospt.2022.10952.

Preseason Clinical Shoulder Test Results and Shoulder Injury Rate in Adolescent Elite Handball Players: A Prospective Study.

OBJECTIVE: To investigate whether adolescent elite female and male handball players with shoulder muscle weakness, deficits in shoulder rotation range of motion (ROM) or in joint position sense (JPS), or scapular dyskinesis in the preseason had a higher rate of new shoulder injuries compared to players without these characteristics. DESIGN: Prospective cohort study. METHODS: We studied 344 uninjured players (452 player-seasons, 50% female). We measured their shoulder strength in isometric external rotation (IER), isometric internal rotation (IIR), isometric abduction, and eccentric external rotation, as well as their shoulder ROM, JPS, and scapular dyskinesis, during the preseason. Players were monitored weekly regarding match and training hours and shoulder injuries during 1 or 2 seasons. We used multivariable Cox proportional hazard models to calculate hazard rate ratios related to the first injury and 95% confidence intervals (CIs). RESULTS: During 2 seasons, the participants reported 48 new shoulder injuries. In female players, the hazard rate ratio was 2.37 (95% CI: 1.03, 5.44) for IER weakness and 2.44 (95% CI: 1.06, 5.61) for IIR weakness. The hazard rate ratio was 0.85 (95% CI: 0.39, 1.83) for an IER/IIR ratio of less than 0.75 and 1.53 (95% CI: 0.36, 6.52) for scapular dyskinesis. In male players, the hazard rate ratio was 1.02 (95% CI: 0.44, 2.36) for IER weakness, 0.74 (95% CI: 0.31, 1.75) for IIR weakness, 2.0 (95% CI: 0.68, 5.92) for an IER/IIR ratio of less than 0.75, and 3.43 (95% CI: 1.49, 7.92) for scapular dyskinesis. There were no associations between new shoulder injuries and deficits in ROM or JPS. CONCLUSION: In adolescent elite handball, male players with preseason scapular dyskinesis and female players with preseason IIR or IER shoulder weakness had an increased shoulder injury rate. J Orthop Sports Phys Ther 2020;50(2):67-74. Epub 27 Nov 2019. doi:10.2519/jospt.2020.9044.

Risk factors for, and prevention of, shoulder injuries in overhead sports: a systematic review with best-evidence synthesis.

OBJECTIVE: To assess the evidence for risk factors and prevention measures for shoulder injuries in overhead sports. DESIGN: Systematic review with best-evidence synthesis. DATA SOURCES: Medline (Ovid), PubMed (complementary search), Embase (Elsevier), Cochrane (Wiley), SPORTDiscus (Ebsco) and Web of Science Core Collection (Thomson Reuters), from 1 January 1990 to 15 May 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials, cohort studies and case-control studies on risk factors or prevention measures for shoulder injuries in overhead sports. The eligible studies were quality assessed using the Scottish Intercollegiate Guidelines Network criteria. RESULTS: Of 4778 studies identified, 38 were eligible for quality review and 17 met the quality criteria to be included in the evidence synthesis. One additional quality study presented a shoulder injury prevention programme. Most studies focused on baseball, lacrosse or volleyball (n=13). The risk factors examined included participation level (competition vs training) (n=10), sex (n=4), biomechanics (n=2) and external workload (n=2). The evidence for all risk factors was limited or conflicting. The effect of the prevention programme within the subgroup of uninjured players at baseline was modest and possibly lacked statistical power. CONCLUSIONS: All investigated potential risk factors for shoulder injury in overhead sports had limited evidence, and most were non-modifiable (eg, sex). There is also limited evidence for the effect of shoulder injury prevention measures in overhead sports. PROSPERO TRIAL REGISTRATION NUMBER: CRD42015026850.

Female adolescent elite handball players are more susceptible to shoulder problems than their male counterparts.

PURPOSE: Shoulder problems are frequent among senior elite handball players. The objective of this study was to assess the prevalence of shoulder problems among adolescent elite handball players and to investigate potential differences in gender, school grade, playing position and playing level. METHODS: During the 2014 and 2015 pre-season periods, 471 players (age 15-18 years, 54% female) completed a comprehensive baseline questionnaire regarding history of any shoulder pain and shoulder problems experienced during the past season. The players were monitored weekly for one competition season (September-April) regarding shoulder problems and the amount of match and training. Generalised linear models with a binomial link function were used to calculate a prevalence ratio (PR) with 95% confidence interval (CI) to compare the subgroups of players. RESULTS: In total, 110 players (23%) reported having substantial shoulder problems (defined as moderate/severe reduction in training volume, or moderate/severe reduction in performance, or complete inability to participate) at some point during the follow-up season, of which almost half reported complete inability to participate. Of those players reporting substantial problems, 43% (95% CI 39-48) did so for at least 3 consecutive weeks during the season. The prevalence was significantly higher in female players (PR 1.46, 95% 1.04-2.06) and in backcourt players (PR 1.58, 95% CI 1.08-2.32), but no differences were found for school grade (PR 1.21 95% CI 0.88-1.67) or playing level (PR 1.09 95% CI 0.76-1.56). CONCLUSIONS: The prevalence of substantial shoulder problems in adolescent elite handball players is high, especially among females, and this warrants further studies on risk factors for shoulder injury and the development of prevention strategies in handball players already before the age of 15. These findings also highlight the importance of introducing a clinical monitoring programme on a routine basis and improving the medical support, taking gender-related aspects into consideration, at handball-profiled secondary schools. LEVEL OF EVIDENCE: II.

A prospective cohort study identifying risk factors for shoulder injuries in adolescent elite handball players: the Karolinska Handball Study (KHAST) study protocol.

BACKGROUND: Handball is a physical contact sport that includes frequent overhead throwing, and this combination leads to a high rate of shoulder injuries. Several factors have been associated with shoulder injuries in overhead athletes, but strong scientific evidence is lacking for most suggested risk factors. We therefore designed the Karolinska Handball Study (KHAST) with the aim to identify risk factors for shoulder injuries in adolescent male and female elite handball players studying at handball-profiled secondary schools in Sweden. Secondary objectives are to investigate whether shoulder function changes during the competition season and whether the physical profile of the players changes during their time in secondary school. METHODS: Players aged 15 to 19 years were included during the pre-season period of the 2014-2015 and the 2015-2016 seasons. At inclusion, players signed informed consent and filled in a questionnaire regarding playing position, playing level, previous handball experience, history of shoulder problems and athletic identity. Players also completed a detailed test battery at baseline evaluating the shoulder, neck and trunk. Players were then prospectively monitored weekly during the 2014-2015 and/or 2015-2016 competitive seasons regarding injuries and training/match workload. Results from the annual routine physical tests in the secondary school curriculum including bench press, deep squat, hand grip strength, clean lifts, squat jumps, counter movement jumps, <30 m sprints, chins, dips and Cooper's test will be collected until the end of the competitive season 2017-2018. The primary outcome is the incidence of shoulder injuries and shoulder problems. The secondary outcome is the prevalence of shoulder injuries and shoulder problems. DISCUSSION: Shoulder problems are frequent among handball players and a reduction of these injuries is therefore warranted. However, in order to introduce appropriate preventive measures, a detailed understanding of the underlying risk factors is needed. Our study has a high potential to identify important risk factors for shoulder injuries in adolescent elite handball players owing to a large study sample, a high response rate, data collection during consecutive seasons, and recording of potential confounding factors.

Three combinations of manual therapy techniques within naprapathy in the treatment of neck and/or back pain: a randomized controlled trial.

BACKGROUND: Manual therapy as spinal manipulation, spinal mobilization, stretching and massage are common treatment methods for neck and back pain. The objective was to compare the treatment effect on pain intensity, pain related disability and perceived recovery from a) naprapathic manual therapy (spinal manipulation, spinal mobilization, stretching and massage) to b) naprapathic manual therapy without spinal manipulation and to c) naprapathic manual therapy without stretching for male and female patients seeking care for back and/or neck pain. METHOD: Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of Naprapathögskolan - the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 1057) were randomized to one of three treatment arms a) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage), b) manual therapy excluding spinal manipulation and c) manual therapy excluding stretching. The primary outcomes were minimal clinically important improvement in pain intensity and pain related disability. Treatments were provided by naprapath students in the seventh semester of eight total semesters. Generalized estimating equations and logistic regression were used to examine the association between the treatments and the outcomes. RESULTS: At 12 weeks follow-up, 64% had a minimal clinically important improvement in pain intensity and 42% in pain related disability. The corresponding chances to be improved at the 52 weeks follow-up were 58% and 40% respectively. No systematic differences in effect when excluding spinal manipulation and stretching respectively from the treatment were found over 1 year follow-up, concerning minimal clinically important improvement in pain intensity (p = 0.41) and pain related disability (p = 0.85) and perceived recovery (p = 0.98). Neither were there disparities in effect when male and female patients were analyzed separately. CONCLUSION: The effect of manual therapy for male and female patients seeking care for neck and/or back pain at an educational clinic is similar regardless if spinal manipulation or if stretching is excluded from the treatment option. TRIAL REGISTRATION: Current Controlled Trials ISRCTN92249294.

Adverse events after manual therapy among patients seeking care for neck and/or back pain: a randomized controlled trial.

BACKGROUND: The safety of the manual treatment techniques such as spinal manipulation has been discussed and there is a need for more information about potential adverse events after manual therapy. The aim of this randomized controlled trial was to investigate differences in occurrence of adverse events between three different combinations of manual treatment techniques used by manual therapists (i.e. chiropractors, naprapaths, osteopaths, physicians and physiotherapists) for patients seeking care for back and/or neck pain. In addition women and men were compared regarding the occurrence of adverse events. METHODS: Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 767) were randomized to one of three treatment arms 1) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage) (n = 249), 2) manual therapy excluding spinal manipulation (n = 258) and 3) manual therapy excluding stretching (n = 260). Treatments were provided by students in the seventh semester of total eight. Adverse events were measured with a questionnaire after each return visit and categorized in to five levels; 1) short minor, 2) long minor, 3) short moderate, 4) long moderate and 5) serious adverse events, based on the duration and/or severity of the event. Generalized estimating equations were used to examine the association between adverse event and treatments arms. RESULTS: The most common adverse events were soreness in muscles, increased pain and stiffness. No differences were found between the treatment arms concerning the occurrence of adverse event. Fifty-one percent of patients, who received at least three treatments, experienced at least one adverse event after one or more visits. Women more often had short moderate adverse events (OR = 2.19 (95% CI: 1.52-3.15)), and long moderate adverse events (OR = 2.49 (95% CI: 1.77-3.52)) compared to men. CONCLUSION: Adverse events after manual therapy are common and transient. Excluding spinal manipulation or stretching do not affect the occurrence of adverse events. The most common adverse event is soreness in the muscles. Women reports more adverse events than men. TRIAL REGISTRATION: This trial was registered in a public registry (Current Controlled Trials) (ISRCTN92249294).