Category Archives: Uncategorized

Concussion Disclosure Behaviors Attitudes Norms and Knowledge – The BANK Study

Research Team: Johna K. Register-Mihalik, Stephen W. Marshall, Kenneth L. Cameron, Paula Gildner, Kevin M. Guskiewicz, Heidi J. Hennink-Kaminski, Megan N. Houston, Zachery Y. Kerr, Laura A. Linnan, Karen Y. Peck, Melissa C. Kay, Alyse Dorman

Picture1Why did you do this study?

While we aim to identify and treat all concussions, when athletes and soldiers get hurt, the societal and self-imposed pressures to excel, prevent them from admitting that they are concussed. It is imperative that we understand factors that influence the behavior of concussion disclosure and the culture in which both athletes and service academy cadets operate. Knowledge of these factors will aid in development of culturally and organizationally relevant interventions to improve disclosure and to improve prevention and treatment of concussion in at-risk populations. Finally, it is important to develop evidence and community informed educational tools and systems for these groups. Recent studies estimate that over 50% of concussions may not be reported or disclosed and that individuals who delay reporting of concussion may have a longer recovery than those who seek immediate care.


What did you do and what did you find in this study?

The primary goal of the Concussion Disclosure Behaviors Attitudes Norms and Knowledge Study (BANK) is to develop a theory-driven intervention that changes norms and personal beliefs around concussion disclosure among military service academy cadets and collegiate athletes. Fundamental to the intervention is an online interactive platform. We are building an evidence base founded on behavioral theory that will be utilized to create an evidence-based, theory driven intervention. This immersive platform is being developed and tested among physically-active civilian and military emerging adults to refine and produce an interactive educational tool ready for use.

In collaboration with our colleagues at Keller-Army Hopspital, we are building:

1)    A large database of key drivers of concussion disclosure

2)    An interactive and immersive online platform for concussion education that changes cultural norms, attitudes, and behaviors around concussion disclosure.

3)    A network of access to make this tool available freely to NCAA colleges and military installations.

4) A research infrastructure to study how this approach works to change cultural norms, personal attitudes, and behaviors around concussion

Picture3To date we have enrolled nearly 1000 first-year service academy cadets and 350 student-athletes across our two study sites. Our data are yielding results that highlight the key role of intention to disclose concussion symtpoms and it’s influence on actual disclosure behaviors. In addition, our data support the need to develop multi-level interventions that target various levels within sport as perceived social pressures from key stakeholders (eg supervisors, coaches, fellow teammates or cadets, etc) strongly influence intention to disclose and actual disclosure.

We have begun initial development and testing of the immersive platform and are aiming to have this available for use in the next calendar year.

This study:

  • Provides data on key factors to address in development and implementation of concussion prevention and management interventions in at-risk populations
  • Highlights the importance of including multiple levels of society and organizations in intervention development, as perceived social pressures by key individuals plays a role in intentions and behaviors
  • Provides opporutnities to better understand concussion disclosure and care in at-risk populations
  • Provides a resource to improve behaviors around these core issues

Early cartilage degenerative changes in individuals with chronic ankle instability

Research Team Members: Kyeongtak Song (PhD Student in Human Movement Science), Dr. Brian Pietrosimone, and Dr. Erik Wikstrom

Why did you do this study?

kt1Lateral ankle sprains are an extremely common musculoskeletal injury and about 40% of individuals who sprain their ankle develop chronic ankle instability (CAI), a condition characterized by recurrent ankle sprains and instability of the ankle joint. Additionally, recurrent ankle sprains are a common etiology for ankle post-traumatic osteoarthritis (PTOA). Roughly 12% of symptomatic OA is attributable to lower extremity PTOA and 80% of all ankle OA cases are post-traumatic in nature. Previous studies indicate that up to 78% of those with CAI develop ankle PTOA.

However, these data were obtained via arthroscopic visualization (i.e. during surgery) or using standard MRI at the end stage of OA. There is no cure for OA; thereby no therapy exists which can repair joint damage after OA has caused joint damage. Earlier detection techniques are needed if, early treatment strategies to slow the progression of PTOA are to be applied.  Therefore, it is important to detect degenerative changes at the earliest stage (molecular level) before irreversible tissue damage occurs.  Previous studies have shown that decreased proteoglycan density and increased water content are representative of early degenerative changes of the cartilage.  However, these changes are difficult to capture with plain radiography (X-ray), arthroscopy, or conventional MRI. Proteoglycans are one of the main components of the extracellular matrix of the cartilage. One of their functions is to bind with water and provide the basis for absorbing high compressive loads. Therefore, decreased proteoglycan density within articular cartilage indicate worse cartilage health.


The T1ρ MRI technique is a specialized sequence that has been developed for predominantly for cartilage imaging. The T1ρ MRI method can quantify proteoglycan density in the cartilage and provides the earliest possible detection of PTOA pathogenesis. Patients with CAI are at an increased risk of ankle PTOA, suggesting that CAI represents an important contribution to the early stages of ankle joint degeneration. Therefore, the purpose of this study was to determine if early degenerative changes of the talar cartilage were present in those with CAI compared to the healthy controls using T1ρ MRI.

What did you do and what did you find in this study?

We completed ankle MRI scans for 16 CAI patients and 16 healthy controls. They arrived at our biomedical-imaging center 30 minutes prior to the scan and remained seated to unload the ankle cartilage. We used a high resolution T1ρ relaxation time mapping technique, which quantified the interaction between water molecules and cartilage with the surrounding environment. Then, we manually segmented the talar cartilage of the t1rho image and identified four regions of interest (ROI): anteriomedial (AM), anteriolateral (AL), posteriomedial (PM), and posteriolateral (PL). Our main outcomes were the mean T1ρ relaxation times, an indicator of proteoglycan density, in each region of interest and compared these values between the CAI and control groups. Greater T1ρ relaxation times is interpreted as being associated with reduced proteoglycan density and worse cartilage health.


We found that those with CAI had higher mean T1ρ relaxation times relative to uninjured controls for all ROI, particularly in the AL region. This shows decreased proteoglycan density in talar cartilage in individuals with CAI compared to the healthy individuals and indicates that early cartilage degenerative changes are present in those with CAI.

KT Fig2

How do these findings impact the public?

Our findings suggest individuals with CAI have signs of early talar cartilage degeneration, which may be a key mediator driving the progression to PTOA. Ankle sprains are often erroneously deemed as an innocuous injury and many individuals do not seek appropriate care. However, evidence clearly shows a high prevalence of CAI and long-term negative consequences among those whom have sustained a lateral ankle sprain. Therefore, it is important to have proper treatment to prevent the development of CAI and ankle PTOA after you have sustained a lateral ankle sprain.

Our next step will be to understand how to slow the progression of ankle PTOA in those with CAI. Therefore, further research will focus on determining if early intervention programs restore appropriate biomechanics and maximize cartilage health to slow the progression of ankle PTOA in those with CAI.

Comparison of Internal Training Load Between Soccer Athletes Demonstrating “Excellent” and “Poor” Movement Quality

Tara Condon (Second Year Masters Student in Athletic Training) is the author of this week’s EXSS Impact Post.  Tara presented her work at the Second World Congress of Sports Physical Therapy (Optimal Loading in Sport), which was held at the Titanic Belfast in Northern Ireland.

Why did you do this study?

taraSports medicine clinicians can use clinical movement assessments to identify individuals who may be at increased risk of suffering a lower extremity (LE) musculoskeletal injury.1,2  Injury risk identification is often performed during pre-season screenings, which includes the assessment of an athlete’s biomechanics.2 Baseline clinical movement screenings (such as the Landing Error Scoring System (LESS)) can be used as valuable tools to help identify athletes with high-risk movement strategies. The LESS is a reliable and valid screening tool used to identify individuals at greater risk for LE injury.3,4 Clinicians can monitor injury risk via training load (TL) evaluation throughout a season.5,6 It is currently unknown if biomechanics influence in-season TLs. The aim of this investigation was to examine how an athlete’s LE movement quality influences a season’s relative TL (acute:chronic workload ratio (ACWLR)) in American collegiate soccer players over the course of one traditional season.

What did you do and what did you find in this study?

lessFourteen American male collegiate soccer players participated in this pilot study as part of their standard care. Prior to the season, athletes performed 3 jump-landings from a 30-cm high box to a target line placed ½ of the individual’s height from the front of the box. Athletes were instructed to jump from the box, land in front of the line and then immediately jump for maximum height. A Microsoft® depth sensor capable of capturing human movement – was used instead of standard video cameras. Specialized online software, Physimax®, was used to analyze jump-landing performance. Physimax’s® movement assessment algorithms have been identified to be a valid and reliable for identifying movement errors during the LESS.

Daily session RPE (sRPE) were collected during the traditional season utilizing a modified Borg scale of perceived exertion. sRPE and duration were used to calculate internal TLs and weekly ACWLR7. The season’s trends can be observed in the figure below. ITL data was collected as whole integer on the RPE scale from 1-10 and duration recorded to the nearest minute. ACWLRs were calculated starting five weeks into each season. Fig. 2 represents the team’s average absolute weekly TL, as well as the average weekly ACWLR for the season. We compared early season absolute weekly TL, and early season ACWLR between individuals with poor movement profiles (LESS scores (8-11)) and excellent movement profiles (LESS scores (≤ 4)).


Our results suggest that movement quality associated with musculoskeletal injury risk may influence early season TLs in collegiate male soccer athletes. sRPE x duration is a pragmatic, cost effective means of tracking loads (ITL) experienced by an athlete. There is a lack of data surrounding American collegiate field sport athletes. There are no data that examine the relationships between biomechanical risk factors and training load. Future investigations with larger sample sizes should explore the influence of movement quality on training load responses.


How do these findings impact the public?

With a rise in sport participation rates and injury incidence, there is an increased demand to properly plan training sessions in order to effectively manage the loads imposed upon athletes during sport participation.8,9  Within the current literature, no investigation currently includes a meaningful sample of American collegiate athletes5. There is an increased need to include a wider variety of different sports and demographics in TL research in order to establish a more complete risk profile between different sports, gender and age groups.5,10 Thus, the aims of our future research project will be to examine the associations between the relative rates of internal training load, LE movement quality and how they interactively influence injury risk in American collegiate soccer athletes throughout two traditional seasons.


  1. Murphy DF, Connolly DJ, Beynnon BD. Risk factors for lower extremity injury: a review of the literature. Br J Sports Med. 2003;37(1):13-29.
  2. Conley KM, Bolin DJ, Carek PJ, et al. National athletic trainers’ association position statement: Preparticipation physical examinations and disqualifying conditions. J Athl Train. 2014;49(1):102-120.
  3. Padua DA, Marshall SW, Boling MC, et al. The Landing Error Scoring System (LESS) is a valid and reliable clinical assessment tool of jump-landing biomechanics: The JUMP-ACL study. Am J Sports Med. 2009;37(10):1996-2002.
  4. Padua DA, DiStefano LJ, Beutler AI, et al. The landing error scoring system as a screening tool for an anterior cruciate ligament injury-prevention program in elite-youth soccer athletes. J Athl Train. 2015;50(6): 589-595.
  5. Drew MK, Finch CF. The relationship between training load and injury, illness and soreness: A systematic and literature review. Sports Med. 2016;46(6):861-883.
  6. Foster C, Florhaug JA, Franklin J, et al. A new approach to monitoring exercise training. J Strength Cond Res. 2001;15(1):109-115.
  7. Malone S, Owen A, Newton M, et al. The acute:chonic workload ratio in relation to injury risk in professional Soccer. J Sci Med Sport. 2017; 20(6): 561-565.
  8. Gabbett TJ. The Development and Application of an Injury Prediction Model for Noncontact, Soft-Tissue Injuries in Elite Collision Sport Athletes. J Strength Cond Res. 2010;24(10):2593-2603.
  9. Orchard JW, James T, Portus M, Kountouris A, Dennis R. Fast bowlers in cricket demonstrate up to 3- to 4-week delay between high workloads and increased risk of injury. Am J Sport Med. 2009;37(6):1186-1192.
  10. Hulin BT, Gabbett TJ, Blanch P, Chapman P, Bailey D, Orchard JW. Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers. Br J Sports Med. 2014;48(8):708-712.


Sport Specialization and Psychosocial and Physical Health Outcomes in College Students

This week’s EXSS Impact Post was developed by Shelby Waldron (senior, EXSS and Psychology major, SURF program participant) and J.D. DeFreese, PhD (faculty advisor)

JD Pic 1Why did you do this study?

Recently there has been a movement towards sport specialization (high intensity, year- round training in a single sport, with the exclusion of other sports), evident in the increasing number of elite youth sport competitions, such as the Junior Olympics and AAU. There has also been a growing number of position statements, from major medical organizations, proposing specialization as an antecedent of maladaptive psychological and physical health outcomes. Two of the most prominent concerns are burnout (the multidimensional psychological syndrome of reduced sense of athletic accomplishment, sport devaluation, and physical and emotional exhaustion) and increased risk of injuries. Despite growing interest, there is little to no empirical support for these claims, especially in regards to psychosocial health outcomes. Therefore, the purpose of this study was to examine the relationship between young adults’ retrospective sport specialization and both past and present physical (i.e. injury risk, physical activity level, and sport attrition) and psychosocial (i.e. burnout, motivation, athlete engagement, perceived social support, perceived sport stress, and resilience) health.

Medical Organization Position Statement
American Medical Society for Sports Medicine “Early sport specialization may increase the risk for overuse injury and burnout and should be avoided at younger ages.”
National Athletic Trainer’s Association “In addition to the potential for repetitive microtrauma and overuse injury, specialization in 1 sport may be associated with … psychological or socialization issues, and ultimately burnout.”
American Academy of Pediatrics “Young athletes who specialize too soon are at risk of physical, emotional, and social problems.”
National Association for Sports and Physical Education “Reduce burnout and dropping out from sports, and maximize the probability of personal development…by discouraging specialization in one sport until a young person can make a fully informed decision.”

What did you do and what did you find in this study?

Data was collected from a convenience sample of one-hundred and fifty college aged individuals (ages 18-23), who completed at least one season of competitive sport in high school.  After consenting, participants completed an anonymous, online Qualtrics survey, at their convenience. The survey included self-reported demographics and retrospective high school sport participation (i.e. sport type, number of total seasons, and average weekly training volume). Participants reflected on their final high school sport season when responding to retrospective psychosocial measures (i.e. athlete burnout, self-determined sport motivation, athlete engagement, perceived social support, and perceived sport stress) and reporting prior injury history. Finally, participants self-reported measures of current psychological (i.e. intrinsic motivation for exercise and psychological resilience) and physical (i.e. physical activity level and sport participation) health.

Psychosocial Variables
  What is it? How Measured?
Athlete Burnout Feelings of emotional and physical exhaustion, devaluation of sport, and reduced sense of athletic accomplishment. Retrospective
Self-determined Sport Motivation Level of different types of intrinsic and extrinsic motivation the individual has towards their sport participation. Retrospective
Athlete Engagement General positive feelings of involvement and success in sport. Retrospective
Perceived Social Support Perceptions of availability of social support if needed, in different situations. Retrospective
Perceived Sport Stress Subjective level of pressure and anxiety associated with sport participation. Retrospective
Psychological Resilience Ability to successfully adapt to life tasks in the face of obstacles or adverse conditions. Current
Intrinsic Motivation for Exercise Level of motivation the individual has towards their current physical activity habits. Current


Physical Health Variables
  What is it? How Measured?
Injury Risk Number of total sports-related injuries pre-college. Type and mechanism of injury (i.e. acute or overuse) for each injury. Retrospective
Vigorous Physical Activity Number of days per week x hours per day of physical activity that causes increased heart rate and heavy breathing. Current
Moderate Physical Activity Number of days per week x hours per day of physical activity that causes slight increases in heart rate and breathing. Current
Sitting Time spent sitting on weekdays and weekends, respectively. Current
Sport Participation Level of current sport participation (i.e. None, Recreational, Club, or Varsity). Current

Overall, participants reported low-to-moderate levels of retrospective global athlete burnout and its three dimensions. However, a majority of the sample (76.7%) experienced a sports-related injury during their athletic career, with an average of approximately 3 injuries. Correlations between study variables were statistically significant and in line with previous theoretical and empirical findings. Additionally, significant associations between specialization factors (i.e. weekly training volume) and both psychological (i.e. burnout) and physical (i.e. past injury rate) health outcomes support an indirect, maladaptive relationship between specialization and health outcomes.

Utilizing a 3-point specialization scale, participants were classified as low, moderate, or highly specialized, with an almost equal split amongst the sample. While minimal significant group differences between specialization groups were found, highly specialized athletes reported significantly lower average levels of reduced accomplishment (a dimension/symptom of athlete burnout) when compared to the moderate specialization group. In addition, highly specialized athletes reported higher levels of integrated motivation (the most autonomous form of extrinsic motivation), compared to low specializers. Together, these adaptive outcomes suggest that the specialization environment may not be inherently maladaptive in regards to athletes’ psychosocial health. Instead, this relationship may be dependent on mediating factors, such as athletes’ reasons for specializing. While exploratory in nature, athletes who reported more adaptive reasons for specializing (i.e. pursuit of athletic excellence), reported significantly higher levels of adaptive outcomes (i.e. athlete engagement and intrinsic motivation for exercise) and lower levels of maladaptive outcomes (i.e. reduced accomplishment and sport stress), compared to other specializers.

Specialization Classification Using 3-point Scale

Specialization Grouping

Number of “Yes” Responses to Questions: 1) Did you quit other sports to focus on a single sport? 2) Did you train > 8 months of the year in a single sport? 3) Did you consider one sport more important than all other sports? Study Sample: n (%)
Low ≤ 1 46 (30.7%)
Moderate 2 60 (40.0%)
High 3 44 (29.3%)

JD Figure1

How do these findings impact the public?

This study serves to further understanding of the costs and benefits of sport specialization, in order to aid in the development of recommendations, guidelines, and interventions to help clinicians treat and prevent maladaptive psychological health outcomes and injuries. Additionally, study findings educate parents, athletes, and coaches, and inform sport governing bodies’ policies. While minimal significant group differences were found, correlational data supports a maladaptive relationship between sport specialization and health outcomes, warranting further research. Additionally, the lack of significant differences may be due to the small number of early specializers (specializing before age 13) in the sample, as this pathway has been posited to carry the most health risks. While limited in scope, the findings contradicted prominent claims by suggesting that the specialization-psychological health relationship may not be inherently maladaptive, but perhaps more complex. For example, psychosocial outcomes associated with sport specialization may be dependent on mediating factors, such as athletes’ reasons for specializing. This study also serves as a first step to corroborate theoretical assumptions with empirical support and verify the utility of future prospective studies. Based on the current findings, directions for future research include: focusing on the effects of early specialization (specializing before age 13) and examining potential mediating factors in the specialization-psychological health relationship.


This research was conducted as part of a Summer Undergraduate Research Fellowship (SURF) for Shelby Waldron through UNC’s Office for Undergraduate Research. The SURF program encourages undergraduate involvement in research via funding of student-led research projects. For more information see OUR’s website:

Short-Term Lower Body Resistance Training Improves Cardiopulmonary Capacity in Sedentary Middle-Aged Females

Research Team Members: Chad Wagoner, Erik Hanson, Eric Ryan, Ryan Brooks, Jordan Lee, Erin Coffman, Claudio Battaglini

Under the direction of Dr. Claudio Battaglini

Why did you do this study?

Maximal oxygen uptake (VO2max) assessed via a graded cardiopulmonary exercise test (CPET) on a treadmill or cycle ergometer is viewed as the “Gold Standard” among exercise physiologists in assessing an individual’s cardiopulmonary capacity. VO2max has many implications as it is indicative of one’s overall physical fitness level, and lower values are often associated with diseases and all cause mortality. Most recently, the results of a CPET have been shown to be a strong independent predictor of survival in certain cancers (i.e. Non-small cell lung cancer, bone marrow transplant, and breast cancer) that may complement traditional markers of prognosis to improve risk stratification and prognostication. In breast cancer patients, a CPET often occurs on a cycle ergometer as opposed to a treadmill in order to reduce the risk of falls stemming from treatment related balance issues and peripheral neuropathy. Previous research has cited limitations in older, sedentary, and cancer populations when completing a CPET on a cycle ergometer. Most commonly, associations among lower limb strength and VO2max values have been reported. This potentially indicates an inability to produce the required amount of strength to withstand the resistance in pedals resulting in prematurely terminating the CPET. The resulting VO2max value may not be truly indicative of the individual’s cardiopulmonary capacity. Therefore, more research is needed to explore the relationship between lower limb strength and the determination of maximum cardiopulmonary capacity. By doing so, the precision of assessing cardiopulmonary capacity can be improved in those with reduced lower limb muscular function.

Previous research has examined the impact of resistance training on cardiopulmonary capacity in many different populations ranging from healthy populations to those that have been diagnosed with cancer. However, for certain populations, the results can be doubtful and controversy is often discussed among the exercise physiology community. Overall conclusions are that resistance training may have a positive influence on cardiopulmonary capacity, even more so when using cycle ergometry on those who are either sedentary or have no experience with cycling. Most of the studies to date that have examined the effects of resistance training on cardiopulmonary capacity used training protocols lasting from 5 weeks up to 6 months. Protocols of this length limit the practical application in a clinical setting, where a precise assessment is needed quickly, often within a week of hospitalization or at the beginning of a clinical trial. Further, previous literature has shown that in sedentary populations, strength gains in response to a resistance training program can be attained as early as 2 weeks; improvements that are mainly attributed to neuromuscular adaptations. Nevertheless, these neuromuscular adaptations can in turn allow for individuals to produce greater force during the CPET, thus attaining a higher and potentially a more precise characterization of their “true” cardiopulmonary capacity. To our knowledge, no other study has examined the relationship of resistance training’s impact on cardiopulmonary capacity over such short period of training (2 microcycles) in sedentary middle-aged women. The premise of this study was to evaluate a population of women who are of similar age and fitness level of those women who are often diagnosed with breast cancer. Therefore, the purpose of this study was to examine the impact that a microcycle of two weeks of resistance training had on VO2max in sedentary middle-aged females.

What did you do and what did you find in this study?

Initially, participants underwent a screening for participation in a maximal CPET and strength testing. After the approval from a cardiologist, all participants were familiarized with all testing procedures. We then proceeded to measure maximal cardiopulmonary capacity on a cycle ergometer and lower limb strength on an isokinetic dynamometer in 25 sedentary middle-age females within 1 week of familiarization and after the 2 weeks of lower body resistance training.


Those who were in the intervention arm completed 2 weeks of lower body resistance training (6 total sessions) consisting of leg press, leg extension, and leg curl exercises. Training loads for the 2 weeks of resistance training were determined by completing a 1-Repetition Maximum (1-RM) for the exercises listed above. Training loads for each visit can be seen in the table below. Those in the control group were asked to not change their current activity level or diet throughout the same time period.

Training Program Visits 1 & 2 Visits 3 & 4 Visits 5 & 6
Load (% 1RM) 65% 1-RM 10% increase from previous load 10% increase from previous load
Reps X Sets 2 X 10-15 2 X 10-15 2 X 8-10

Participants who completed the 2 weeks of lower body resistance training exhibited overall greater strength gains in the lower limbs as well as significantly improving their cardiopulmonary capacity.

Mean Change Scores
Variable Intervention Control
VO2max (ml/kg/min) + 2.1 ml/kg/min -1.9 ml/kg/min
Lower Limb Strength (Nm) +6.0 Nm -1.2 Nm

How do these findings impact the public?

These preliminary findings suggest that that 2 weeks of lower body resistance training can improve leg extensor strength in sedentary middle-aged women, providing them with better preparation to perform a CPET on a cycle ergometer; therefore, a more precise measurement of their cardiorespiratory capacity can be obtained. Clinicians and practitioners will in turn be able to interpret CPET data with greater confidence in regards to the individual’s health status and fitness level. Further, the data can be utilized to design training protocols with greater accuracy in this population, allowing for optimal adaptations to aerobic exercise. Compared to previous research that utilized longer training protocols, our results displayed similar responses in cardiopulmonary values in response to resistance training, however, in a much shorter time period (2-weeks). Future research should implement randomized controlled designs in order to confirm or refute these initial results as well as use this design to test other populations such as cancer patients or any other population that suffers from muscular weakness or generalized physical de-conditioning.


Considerations for Alternative Scheduling and Administrative Models in Intercollegiate Athletics


This week’s EXSS Impact post was developed by Dr. Robert Malekoff and represents work conduted through the department’s Center for Research in Intercollegiate Athletics.

Why did you do this study?

Over the past decade many universities competing at the National Collegiate Athletic Association (NCAA) Division I level have moved from one athletic conference to another. In many cases this national realignment has dramatically enlarged the geographic footprint of conferences leading to two unintended consequences: (a) an increase in travel costs; and (b) more time away from campus for student athletes leading to an increase in missed class time and further segregation of students participating on intercollegiate teams. The primary purpose of the study (commissioned by the Knight Foundation on Intercollegiate Athletics and administered by the Center for Research in Intercollegiate Athletics at UNC- Chapel Hill) was to determine if there was interest among intercollegiate sports leaders for the consideration of alternative scheduling and administrative models that might reduce travel costs and time away from campus/missed class time. An example of an alternative model might have some sports at a university playing a traditional conference schedule, while other sports could be part of a competition grouping that was more regional in nature.

knight commission

What did you do and what did you find in the study?

University presidents, athletic directors, senior woman athletic administrators, faculty athletic representatives, and head coaches from 55 Division I institutions in California, North Carolina, and Virginia (schools that represent conference memberships that span 40 states) were invited to participate in an electronic survey to determine interest in alternative Division I models for competition and administration for different sports.

College-basketball-conference-logos-1024x917Forty-three percent of the respondents expressed interest in exploring alternative models for competition and administration for different sports while 37 percent expressed no interest. The remaining 20 percent of respondents were ambivalent. Approximately one-third of respondents anticipate a decrease in the number of varsity sports offered and athletic scholarships in the next five years, basing these sentiments in part on the current financial climate of intercollegiate athletics. Concern about ever increasing costs associated with college sports programs was more prevalent among less resourced schools in conferences outside the “Power 5” (Atlantic Coast Conference, Big 10, Big 12, Pacific 12, Southeastern Conference).

How do these findings impact the public?

While the study did not reveal an across the broad Division I consensus for specific change, it did reveal high levels of anxiety and uncertainty about the current Division I model of competition among less resourced institutions and conferences. Ideally, the results will serve to encourage university leaders to consider and develop new scheduling and administrative models that might address financial and academic/athletic balance issues that threaten the long term feasibility of Division I athletic programs.

Medial Elbow Joint Space Decreases with Forearm Flexor Contraction – Implications for Elbow Joint Stability & Ulnar Collateral Ligament Injury

Research Team Members: Brett Pexa (PhD Student in Human Movement Science), Dr. Eric Ryan and Dr. Joseph Myers

elbow valgusWhy did you do this study?

Ulnar collateral ligament (UCL) tears, or commonly called ‘Tommy John’ is the tearing of the ligament on the medial portion, or inside, of the elbow. This injury is becoming more common in baseball players, and happening in younger and younger athletes. The ulnar collateral ligament is commonly injured during baseball participation due to the high loads and repetitive stress it experiences during throwing. Baseball pitching exerts a tremendous amount of force on the ulnar collateral ligament and the entire medial elbow. The forces during baseball pitching are up to three times higher than what the ulnar collateral ligament can withstand before tearing. The muscles in the forearm contract to help absorb this force, and previous research in cadaveric and computer models support this hypothesis. The use of diagnostic ultrasound is a quick and reliable way to image living tissue, we are able to look at the medial elbow joint in living tissue to assess how finger and forearm flexor activity can assist in protecting the medial elbow joint.

What did you do and what did you find in this study?


Ultrasound image of medial elbow. Dotted line represents the medial elbow joint space, which was the main measure in this study. (ME = medial epicondyle; TR = trochlea; ST = sublime tubercle; UCL = ulnar collateral ligament)

We measured the medial elbow under 3 different loading conditions: unloaded, loaded, and loaded-contracted. For the unloaded condition, the elbow was at rest. For the loaded condition, we added a cuff weight to the wrist to create stress on the medial elbow joint that mimics baseball pitching. Finally, for the loaded-contracted condition, we added a cuff weight and had the participants grip against a handgrip dynamometer. Our main outcome measure was medial elbow joint space, and this variable was the distance between the humerus (upper arm bone) and the ulna (lower arm bone). The ultrasound machine was placed in a specific location over the medial elbow and 4 specific structures were identified: The medial epicondyle, the ulnar collateral ligament, the trochlea of the humerus, and the sublime tubercle of the ulna (Figure below). Once all 4 of the structures were identified, an image was captured on our ultrasound machine. During the loaded-contracted condition, we made sure all 4 structures were present and the participant was maximally contracting against the grip dynamometer in their hand. The distance from the trochlea to the sublime tubercle was then measured and assessed across conditions. We found that the medial elbow joint space during the loaded condition was larger than the unloaded condition, and the joint space was smaller in the loaded-contracted condition than the loaded condition. This confirmed our hypothesis that the medial elbow joint does assist in absorbing force from the UCL to protect it and prevent it from tearing.


Elbow joint space across 3 loading conditions. The loaded-contracted condition was significantly lower than the loaded condition, indicating that the forearm muscles decrease the medial elbow joint space and subsequently the amount of stress on the medial elbow.

How do these findings impact the public?

These findings help stress how the forearm flexor muscles helps protect the ulnar collateral ligament. With UCL injuries on the rise in professional baseball and happening to younger athletes, rehabilitation and training regimens should address strength of this muscle group. Exercises that address grip strength, wrist strength, and even elbow strength should be added in preseason programs. High function of this muscle group is imperative to health of the UCL and medial elbow joint in baseball pitchers. Future research will investigate how fatigue of this muscle group affects its protective capability of the UCL.


Neural and Muscular Contributions to the Age-Related Reductions in Rapid Strength

We begin the 2017-18 academic year’s EXSS Impact Blog post with a recent publication by Gena Gerstner, who is a PhD student working under the mentorship of Dr. Eric Ryan.  The findings from this research were recently published in the July 2017 issue of Medicine and Science in Sports and Exercise.

The research team supporting this study include multiple masters and PhD students from the Exercise and Sport Science and Human Movement Science graduate programs, respectively.

Why did you do this study?

This is all you now!It is projected that by 2030 the number of older adults aged 65 and over will represent nearly 20% of the total population.  A large percentage of older adults experience functional limitations with everyday tasks and a high incidence of injuries resulting in a significant economic burden.  For example, one out of three older adults experience a fall each year, an event that often times results in accelerated deteriorations in health.

Aging is associated with reductions in maximal and rapid strength, with rapid strength production appearing to decrease to a greater magnitude. These changes are related to mobility limitations and the increased risk of falling. Multiple studies have reported age-related reductions in maximal voluntary isometric strength for the muscles of the lower limb, specifically in the plantarflexors.  The plantarflexors are important for carrying out functional activities and contribute to mobility and overall performance in older adults. Examining skeletal muscle quality and architecture may provide additional insight into factors influencing age-related changes in strength. Although age-related reductions in muscular strength have been well documented, we are aware of no previous studies that have simultaneously examined the neural and muscle specific factors contributing to the age-related reductions in rapid strength.

The purpose of this study was to determine specific mechanisms contributing to the age-related reduction in plantarflexion rapid strength at early (0–50 ms) and late (100–200 ms) time intervals of muscle contraction.

What did you do and what did you find in this study?

Thirty-two young and 20 older recreationally active men performed rapid plantarflexion isometric muscle actions to examine absolute and normalized rapid strength and muscle activation using electromyography at early and late time intervals. Ultrasonography was used to examine medial gastrocnemius muscle size, echo intensity for muscle quality, and muscle architecture [fascicle length and pennation angle].

We found that the older men were weaker, and had lower rapid strength in the later interval of muscle contraction in both absolute and normalized (adjusted to peak strength) terms when compared to the young men.


Absolute torque at 50, 100, and 200 ms for the young and older men during rapid plantarflexion isometric contractions. *P<0.05, significant difference between the young and older men. Data are mean (SD).

The older men also had higher EI (poorer muscle quality), smaller pennation angles, and lower muscle activation in the later interval of contraction. However, we did not observe differences in rapid strength or muscle activation for the early interval of muscle contraction, or in muscle size, or fascicle length between groups. Interestingly, lower late interval rapid strength values were related to poorer muscle quality, smaller pennation angles, and lower muscle activation values; however late interval rapid strength values were no longer related to pennation angle after taking peak torque into account.

How do these findings impact the public?

side-profile-of-calfOur findings indicated that the lack of differences in the early interval of contraction may suggest that older men initially have similar muscle activation to younger men, but are unable to sustain the same rates of muscle activation during the late intervals of contraction. Furthermore, additional factors such as poor muscle quality and smaller pennation angles appear to also play a role in the age-associated changes of rapid strength. These findings add to our understanding of the importance of the various factors that influence the age-related reductions in rapid strength, which has been shown to significantly influence function and performance in older adults.

Metabolic Characterization of Overweight and Obese Adults

Research Team Members: Katie R. Hirsch, Abbie E. Smith-Ryan, Malia N.M. Blue, Meredith G. Mock, Eric T. Trexler, Kristin S. Ondrak

Why did you do this study?

Metabolic syndrome is a chronic disease characterized by the presence of multiple risk factors, including insulin resistance and poor cholesterol, which are associated with an increased risk for the development of cardiovascular disease, type-2 diabetes, and other metabolic diseases. The presence of excess body fat is highly associated with the development of metabolic syndrome, however, previous studies have identified a significant portion of overweight and obese individuals who have no risk factors and are considered metabolically healthy despite having a high percentage of body fat.


Body composition scan using dual-energy x-ray absorptiometry

Despite an apparently normal metabolic status, excess body fat and difficulty achieving a healthy body composition may indicate the presence of underlying metabolic dysfunction overlooked by standard clinical tools. Currently, body mass index (BMI), cholesterol, and blood lipid levels serve as the primary screening tools for health risk.  However, the diagnostic value of these measures is limited by the inability to evaluate body composition (the differentiation between fat mass and lean mass) and fat distribution.  Regional distribution of body fat describes where an individual tends to store body fat.  Greater fat in the abdominal region and around the organs, known as visceral fat, is highly associated with insulin resistance in both overweight and normal weight individuals.  Visceral fat is also more highly associated with metabolic dysfunction than total body fat.  Lean mass (which includes muscle and organs) also has important associations with metabolic health.  Low relative lean mass is associated with insulin resistance, decreased metabolic rate, impaired fat metabolism, and poor functionality in activities of daily living, all of which are associated with weight gain and metabolic dysfunction.  Finally, hormonal imbalances, specifically related to insulin, leptin, estradiol, and cortisol, can lead to an unfavorable distribution of fat in the abdominal region, impair fat and glucose metabolism, and may also negatively impact energy expenditure.


Although traditional metabolic risk factors are highly associated with health risk, a more comprehensive evaluation of metabolic health may be a more appropriate and sensitive approach to evaluating metabolic status, regardless of body weight.   Evaluation of non-traditional metabolic factors, such as visceral fat, lean mass, resting metabolic rate, substrate utilization, and hormonal status, could provide valuable insight into aspects of metabolic health that may otherwise be overlooked. This in turn could improve the detection, prevention, and treatment of metabolic health issues. Therefore, the purpose of this study was to characterize metabolic health in overweight and obese adults using traditional and non-traditional metabolic variables.

What did you do and what did you find in this study?


Resting metabolic rate test using a ventilated canopy and indirect calorimetry.

Body composition, visceral fat, resting metabolic rate, resting substrate utilization (use of carbs or fat for energy at rest), fasting cholesterol, blood lipids, glucose, and the hormones insulin, leptin, estradiol, and cortisol were measured in forty-nine overweight and obese men and women.  When evaluating traditional metabolic risk factors (blood glucose, triglycerides, and HDL cholesterol) 86.7% of the individuals had no more than one risk factor and 92% had no more than two risk factors, meaning this group could be considered metabolically healthy by traditional standards.  When evaluating visceral fat, in addition to traditional risk factors, the proportion of individuals considered to have metabolic dysfunction increased to 28.9%.  The occurrence rate increased to 80% when all metabolic risk factors were considered, classifying a majority of the group as metabolically dysfunctional. For men, the most common risk factors were high LDL cholesterol (82.6%), low metabolic rate (60.9%), low HDL cholesterol (47.8%), and high total cholesterol (43.5%).  For women, low HDL cholesterol (50.0%) and high LDL cholesterol (50.0%) were the most common risk factors, followed by low metabolic rate (30.8%), high visceral fat (19.2%), and greater reliance on carbohydrates for energy at rest (19.2%).

How do these findings impact the public?



Ultrasound image of visceral fat thickness. Measurement was taken from the abdominal muscles to the aorta.

Results of this study show the importance of evaluating metabolic health beyond traditional diagnostic criteria. Evaluating components of body composition and metabolic function, such as visceral fat, lean mass, resting metabolic rate, and substrate utilization, in addition to hormonal and metabolic profiles, can give significant insights into metabolic status regardless of body weight and BMI status.  Knowledge of these factors could significantly improve lifestyle treatment approaches. Further, men and women exhibited different frequencies of risk factors, likely attributable to differences in fat distribution and hormonal status, reinforcing the importance of sex-specific evaluations. A unique aspect of this study was the use of ultrasound to measure visceral fat. Portable equipment, such as ultrasound, can improve the accuracy and evaluation of abdominal obesity-related risk, which is currently not evaluated in a clinical setting.  Additionally, connecting individuals with metabolic specialists who have access to more extensive assessment tools could lead to more effective intervention approaches.




Attenuation of Resting but Not Load-Mediated Protein Synthesis in Prostate Cancer Patients on Androgen Deprivation

Research Team Members: Erik Hanson, Andre Nelson, Daniel West, John Violet, Lannie O’Keefe, Stuart Phillips, Alan Hayes

These findings were recently published in Journal of Clinical Endocrinology and Metabolism, March 2017, 102(3): 1076-1083

Why did you do this study?

Prostate cancer is the most common non-dermatological form of cancer in US men (diagnosed in 1 in 7 men) and is the second leading cause of cancer-related death. In 2017 alone, it is estimated that 161,360 new cases of prostate cancer will be diagnosed with 26,730 deaths.

Androgen deprivation therapy (ADT) is a type of prostate cancer treatment that slows tumor growth but has several side effects, including the loss of muscle mass, strength, and physical function. All of these changes have a negative impact upon health-related quality of life. Exercise interventions have become more common to help reduce treatment-related side effects. Specifically, resistance training during ADT improves muscle strength, reduces fatigue, and enhances physical function. However, it is unclear as to whether or not significant gains in muscle mass are possible during ADT.

Looking at the recent literature, some studies have reported that no muscle hypertrophy occurs with resistance training during ADT. Others have shown that muscle gains are possible but the response is attenuated. Recently, our lab has demonstrated that high intensity resistance training induces gains in lean mass that are comparable to healthy, age-matched controls.

protein-powder-nutritional-supplementProtein supplementation is often used with resistance training to enhance the response. However, very few studies have combined these two muscle building strategies and used them during ADT as a means of preserving lean muscle mass and function and no studies have looked at the muscle protein synthesis response. Determining the acute response initially will provide important information for desiging future resistance exercise and dietary interventions, as it is repeated transient increases in muscle protein synthesis that may lead to increases in lean tissue over time.

Therefore, the purpose of this study was to determine the acute muscle protein response to whey protein supplementation with and without resistance exercise in men being treated for prostate cancer with ADT and healthy controls. We hypothesized that baseline protein synthesis would be suppressed with ADT but that diet- and exercise-induced increased in protein synthesis would be normal.

What did you do and what did you find in this study?

We measured muscle protein synthesis (MPS) from biopsy samples obtained from the thigh muscles at rest and 4h after participants consumed 40g of whey protein (Fed) and 40g of whey protein plus 3 sets of knee extension resistance exercise (Ex-Fed).

Muscle protein synthesis was lower during ADT at rest and while feeding (Fed) increased the rate of synthesis, the response was attenuated. However, the change in muscle protein synthesis from rest to Ex-Fed was similar to healthy controls.


* Significantly different from CON at the specific time point, P<0.01
† Significantly different from baseline value, P<0.001
‡ Significantly different from baseline and FED condition, P<0.001

How do these findings impact the public?

Muscle protein synthesis at rest is lower with ADT, which is likely why there is the loss of muscle mass in these patients. However, muscle protein synthesis increases following large doses of whey protein, although it is not as effective during ADT. But the combination of whey protein and vigorous resistance exercise may be an effective means to offset the side effects of prostate cancer treatment.

Future studies are needed to explore why protein synthesis is activated less with feedling alone, as this ‘anabolic resistance’ may have significant consequences for men on ADT. We are currently developing projects that will help to clarify these findings in the future.