Mental Health and the Athlete

Mental health has become a major talking point during the COVID pandemic with feelings of despair, lethargy, hopelessness, low drive which is compounded by the prevalence of mental health disorders already present in the community with one in five people suffering from a depressive or anxiety disorder. Athletes are not immune from mental health disorders including depression, anxiety and eating disorders which can be associated with sporting performance, injuries, multiple surgeries, maladaptive perfectionism, retirement with rates of depression and anxiety as high as 45% in elite athletes.

Athlete Burnout

Athletes and individuals who train hard will routinely experience symptoms of tiredness, exhaustion, fatigue, reduced motivation, decreased performance which may or may not be associated with increased injuries and often describe feeling “burned out”. However, overtraining and burnout are two different states where burnout can occur in the absence of excessive training stress. Burnout is conceptualised as a psycho-social syndrome comprised of emotional and physical exhaustion, a reduced sense of accomplishment and sport devaluation.

It is the consequence of chronic stress which can result from high training loads, perfectionism, uncertainty around team selection, perceived performance pressure. It is not a transient condition and shares overlapping symptoms with depression such as concentration difficulties, anhedonia (inability to feel pleasure), sleep disturbance, self-criticism, psycho-motor changes, fatigue/exhaustion however burnout and depression are two independent states.

Burnout is characterised by psychophysiological and behavioural changes such as;

  • Struggling to meet personal and professional demands
  • Physically tired and not able to participate in activities
  • Difficulty communicating
  • A feeling of not being supported by the team (coach/support staff)
  • Ongoing disappointment
  • Mentally exhausted
  • Physically exhausted
  • Feel your own contribution to the team is small and isn’t valued by others in the team
  • Feeling like you have no social support

Personality factors have also been associated with burnout in particular perfectionism either striving for perfectionism or concerns about making mistakes.

Consequences of Burnout

Burnout has been shown to lead to a range of negative consequences like depressive mood, decreased commitment to sport, decreased performance, antisocial behaviour including social distancing and termination from sport. Every individual will experience burnout differently as such treatment of burnout needs to be tailored to the individual. Mindfulness based interventions and cognitive behavioural therapy including stress management techniques like breathing, and exercise and cognitive restructuring to help keep an individual’s mind in the present moment while also addressing any issues around perfectionism may be of benefit. Professional interventions such as involving the athlete with any decision-making processes, rotating the athlete to allow for time off from training and/or competition should also be considerations.

It is important that we are acutely aware at understanding and identifying the mental health issues present in the general and athletic population. Burnout although overlapping in symptoms with depression and often associated with overtraining is its own standalone state which can have consequences on the mental health and performance in athletes and professionals.

For one-on-one information, contact Melbourne Chiropractor, Dr. Nick Shannon.

Why is protein important for athletic performance?

In sports where power and strength are important, athletes/individuals need lean muscle mass which occurs through a process called muscle protein synthesis. In short muscle protein synthesis is the remodelling process of skeletal muscle in response to resistance training leading to muscle growth (hypertrophy).

Protein is therefore an important building block for muscle growth and also for nonmuscular structures like tendons and bone. It is thought that adaptations in muscle occur due to a rise in leucine (an amino acid in protein) which triggers off muscle protein synthesis. Resistance training is the main stimulant for muscle protein synthesis, where one bout of resistance training leads to muscle protein synthesis for up to 24 hours.

Types of Protein

There are different types of protein, which commonly come in the form of supplement bars and powders. Many of these products are successful more so through slick marketing than the ingredients involved, with supplement companies usually promoting the more amino acids and secondary compounds the better the product, which is seldomly the case.

The 3 most common types of protein are whey, casein and soy. When these three are compared against each other it is whey protein that is absorbed the fastest and contains the highest leucine content, the most important amino acid for augmenting muscle protein synthesis.

Timing of Protein Ingestion

TThe timing of protein ingestion is extremely important, because if protein ingestion occurs too close together it creates a blunting effect of muscle protein synthesis. As such, protein ingestion needs to occur equally over a 4-5 meals throughout the day with one pre bedtime meal/shake. The pre bedtime intake is important as muscle protein synthesis diminishes throughout the night and a pre bedtime meal can aid to reduce the drop off. As a guide ingesting protein within 2 hours post exercise and every 3-5 hours is a solid approach.

Protein Dosage

Dairy sources of protein appear to be superior to other sources of protein due to the higher leucine content. However, there are reports of increased muscle protein synthesis with lean meat, casein, soy and egg.

For athletic performance, the optimal dosage is .25-.3g per kg. Pre bedtime meals should contain .6g per kg. While the optimal dose for older adults is around 40g per serve. Dosages greater than 40g have not been shown to augment muscle protein synthesis any further, with any excess protein being oxidized (removed).

Anterior cruciate ligament (ACL) knee injuries are devastating injuries that can significantly impact an athlete’s career including ending their ability to return to high level competitive sport. Individuals who suffer an ACL injury have lower self-reported knee function, quality of life and a greater risk of long-term joint morbidity including early osteoarthritis (1,2). Whilst those who undergo reconstructive surgery have lower return to sport rates with relatively high reinjury rates up to 24%, with the greatest risk being in the first 7 months (1,3).

The mean time to return to sport following ACL reconstructive surgery (ACLR) is approximately 7 months with accelerated rehabilitation program as short as 6 months (4,5). However, it has been established that when athletes return to sport following an ACLR they continue to exhibit neuromuscular and biomechanical alterations including quadriceps strength deficits resulting in altered landing patterns (1,6). These deficits may potentially result in higher risks of reinjury to the grafted and/or contralateral knee, all indicating that potentially we are returning our athletes too quickly to play following ACLR.

To investigate further we critically review the Read et.al article “Lower Limb Kinematic Asymmetries in Professional Soccer Players With and Without Anterior Cruciate Ligament Reconstruction: Nine Months is Not Enough Time to Restore “Functional” Symmetry or Return to Performance” in the April 2020 issue of the American Journal of Sports Medicine.

This study examines professional soccer players specifically looking at kinetics, focusing on asymmetries during a counter movement jump (CMJ). The framework for this article is an analytical observational cross-sectional design and although it is not the most robust design format, it enables a cohort to be observed and compared at certain time points across the study. It executes this by dividing athletes into 4 groups, those who are 3-6 months, 6-9 months, >9 months into their ACLR rehabilitation and a control group. Strengths to this observational study are the use of the CMJ as an assessment measurement tool provided the risk of errors is minimized, as well as the use of a control group. Some questions are raised over the participation inclusion criteria as there is no mention of; any current or prior ankle injuries which are prevalent in soccer and can effect landing mechanics (7,8,9,10), which knee was injured dominant or non-dominant leg, if strength asymmetries were present prior to the injury, whether all ACLR participants followed a standardised rehabilitation program, were any players involved with ACL injury prevention programs and the cohort is specific to professional soccer players.

Counter Movement Jump

The study found that jump height (which is linked to an ability to complete tasks at a high level in soccer such as sprinting and change of direction) increased in the first 3-6 months however, it plateaued at 6-9 months and remained well below (3-4cm) the control group after 9 months. Whilst peak power, as measured by dual force plates followed a similar pattern and remained well below (3-4W/kg) the control group after 9 months. There were also significant interlimb asymmetries in the ACLR group during the eccentric (preload and deceleration phases) and concentric (jump phase) which decreased the further out from surgery the participants were, yet significant differences remained after 9 months. Indicating ACLR players were employing an offloading strategy to protect the injured knee. Furthermore, the uninjured limb was the dominant force producer. Both findings are consistent with other similar research indicating the changes occur due to altered nervous system function, strength deficits, reduced range of motion and fear of reinjury. The over reliance on the dominant limb for peak force production is important as it results in greater torque and stress loading of the knee and if the musculature is unable to dissipate the force effectively during a jump landing it may contribute to higher risk of injury, it may also lead to fatigue and potential injury of the uninjured knee.

The results suggest that even after 9 months soccer players who have undergone ACLR are showing power, strength, and asymmetries between limbs with lower power and jump height figures compared to healthy controls. Knowing that strength deficits are associated with reinjury rates in a variety of lower limb injuries, it would suggest that potentially players are being returned to play before they are ready, increasing their risk of reinjury (11,12).

Although this study has its weaknesses the results are consistent with those in similar studies looking a landing patterns in participants following ACLR helping to build on the available evidence that limb kinetic asymmetries exist in ACLR patients up to and greater than 9 months (1,6,13). These findings together suggest that longer recovery times are warranted, and individuals should only be returned to play following ACLR when they have limb asymmetries within a tolerable limit. Read et.al recommend benchmark goals such as, a jump height of 33-35cm and a concentric impulse asymmetry of no more than 2.5-3.1%. They also provide quartile figures, enabling clinicians to establish whether an individual is progressing quickly or slowly with their rehabilitation based on the CMJ metrics. They also point out that inter limb differences are task, variable and physical quality specific, meaning limb differences will occur across different tests and variables in the same task therefore using one asymmetry metric such as a single leg hop test with a <10% asymmetry isn’t an appropriate guide to determine progression and return to play status. A combination of tasks should be used including single leg hop, isokinetic strength, CMJ analysing the different variables in the task ie. height, power etc.

ACL injuries are devastating knee injuries and it is paramount to reduce the risks of reinjury that athletes are not rushed back prematurely, furthermore evidence shows a 50% reduction in reinjury rates for every month return to sport is delayed up to 9 months post-surgery (5). Focusing on reducing lower limb strength asymmetry, especially improving quadriceps strength is vitally important in helping to monitor an athletes ACLR progress and in determining when they are ready to return safely to sport. Consideration should also be given to ACL injury prevention programs which have been shown to reduce the risk of ACL injures by 53%, with any program consisting of strength, plyometrics, agility, balance and flexibility exercises (2).

For more interested blog articles check out the Shannon Clinic blog page.

Whether you are reading a social media post, a blog, a newspaper article, or a journal paper it should always be read with a critical mind and never taken at face value.

In the world of medical and scientific journal articles it is all too easy to be drawn to an attractive title like “PRP superior to coritsone for lateral elbow pain: meta-anaylsis” to only read through the abstract taking the conclusion as gospel, because after all the title says it’s a meta-analysis which means the paper has to be solid right?

It is true that the strength of an article lies in its design with meta-analysis and systemic reviews at the top of the tree, followed by blinded randomised controlled trials, right down to case reports and editorials. Nevertheless, study design alone is not enough to be able to truly trust an article’s findings.

One must consider the methodology used and how easily it be can be reproduced, in addition to the strength and weaknesses of the selection (inclusion/exclusion) criteria including the outcome measures used. For example, if we are examining tendinopathy and the diagnosis is confirmed by physical examination alone without ultrasound, how many patients in the study will have confirmed tendinopathy? Even if those patients have been selected carefully, they are still at risk of dropping out of the study, which can have disastrous effects on the outcome of a study. As statistical power, or the number of participants required to be able to detect an effect is a vitally important.

Articles are also open to the risk of bias, confounders, errors, and chance which can all influence the outcomes of a study. It maybe the study has selected participants who are known non or strong responders to an intervention being tested, called selection bias. A strong study design aims to mitigate the risks of these occurring however, understanding their impact on a study is imperative when critically reviewing what you are reading. Additionally, articles often use statistical measurements such as, measures of associations and measures of heterogeneity including odds ratio, hazard ratio, relative risk, P value, I2 understanding these is crucial to be able to interpret the results.

Lastly, when consideration has been given to all of these aspects thought must then be given to the results and how they compare to other reputable research available in that area. Are the results consistent with other research, if not why? What research has been used to support their findings and is that research reputable and high quality? Do the results add weight to the existing research to further support an outcome? Do they give rise to a rethink about the existing research? Do they create a new higher standard or intervention? Or did the study use a weak design or were the results influenced by bias, confounders, errors, chance, or a high dropout rate, or poor selection criteria leading one to question the quality of the study’s findings?

Understanding what you are reading in this day in age where “authorities” are in endless supply is extremely important. Regardless of what you are reading, always sit back and ask yourself questions about what you are reading, who is writing it, why are they writing it, how robust is the article, what quality of evidence is it supported by, and are there any parties who will benefit from the results. 

For more interested blog articles check out the Shannon Clinic blog page.