ISSN: 1543-9518

A Manual Therapy Treatment for Headache Pain

Authors: Lindsay C. Luinstra1, Dan Sigley1, Heidi A. VanRavenhorst-Bell1

Corresponding Author:

Dr. Lindsay Luinstra, DAT, MS, LAT, ATC

1845 Fairmount Street,

Box 16,

Wichita, KS 67260

[email protected]

(316) 978-5440


1Department of Human Performance Studies, Wichita State University, Wichita, KS, USA

Dr. Lindsay Luinstra, DAT, MS, LAT, ATC is an assistant professor of athletic training at Wichita State University in Wichita, KS. Her research interest is in sports medicine and manual therapy techniques to treat athletic-related injury.

Dr. Dan Sigley, DAT, LAT, ATC is an assistant professor of athletic training at Wichita State University in Wichita, KS. His research interest is in concussion education, evaluation, and treatment paradigms.

Dr. Heidi A. VanRavenhorst-Bell, PhD is Chair and Associate Professor in the Department of Human Performance Studies and Manager of the Human Performance Laboratory at Wichita State University. She has an established interdisciplinary line of research directed toward functional performance across exercise physiology and orofacial myology.

ABSTRACT

Cervicogenic headache (CEH) is caused by dysfunction in the cervical spine and surrounding muscles. It is typically characterized by unilateral or sometimes bilateral head pain, often accompanied by limited neck movement.  Postural and neuromuscular dysfunction in the cervical spine may contribute to the onset of headache-related pain. This study aims to address headache-related pain using the C2 evaluation and treatment protocol from the MyoKinesthetic System, a manual therapy method focused on evaluating and treating postural imbalances.  A female patient with self-reported chronic headache-related pain and neck discomfort underwent six treatments using the C2 cervical nerve root protocol over a two-week period, with 48-72 hours between each session. Each treatment lasted approximately 8 minutes. Subjective and objective outcome measures were collected throughout the treatment period, including clinician-assessed cervical range of motion, the Numerical Pain Rating Scale (NPRS), the Neck Disability Index (NDI), and the Headache Impact Test-6 (HIT-6). At the initial assessment, the patient reported an NPRS score of 4/10, an NDI score of 14/50, and a HIT-6 score of 58.  After the final treatment, the patient’s NPRS pain score was 5/10, with NDI and HIT-6 scores of 15/50 and 54, respectively. Cervical extension range of motion improved by 7 degrees post-treatment. However, the average NPRS pain reduction over the two weeks was only 0.25 points and not clinically significant. At the 30-day follow-up, NPRS results met the minimally clinically important difference (MCID), with a score of 0. Headache frequency decreased from daily to once every three days, with the duration reduced to around 15 minutes. The patient reported improved tolerance for physical activities and fewer work disruptions. Lasting improvements were observed in neck function, headache impact, pain, and range of motion.  These findings are promising, but more research is needed to confirm the MyoKinesthetic System’s effectiveness for CEH. Targeting the C2 cervical nerve root helped reduce the patient’s chronic headache frequency and neck discomfort, suggesting potential for addressing neuromuscular imbalances. However, since this is a single case study, further research with larger samples and comparisons to other treatments is needed to assess its broader efficacy and long-term effects.

Key Words: MyoKinesthetic System; cervical nerve root; head-related discomfort

INTRODUCTION

Cervicogenic headache (CEH) is characterized by pain in the head associated with the cervical spine and cervical musculature (Bogduk, 2001; Bogduk & Govind, 2009; Haldeman & Dagenais, 2001). Sjaastad et al. (1998), along with the International Headache Society (The International Classification of Headache Disorders, 2018), define CEH as a unilateral headache that may also present bilaterally, associated with the cervical spine and muscles. Identifying signs and symptoms, including a reduced active and passive range of motion in the cervical spine leading to mechanical dysfunction, is critical in diagnosing CEH (Sjaastad et al., 1998). Accompanying symptoms may include nausea, vomiting, flushing, dizziness, phonophobia, photophobia, blurred vision, and dysphagia (Sjaastad et al., 1998). The burden of a headache is measured by the degree of pain and suffering experienced by the patient.

Treatment options are available across multiple healthcare specialties (Yang et al., 2010), including athletic training, and treatment choice appears to depend on the specialty of the healthcare provider treating the patient (Smith & Bolton, 2013). Various treatment methods have been studied, both invasive (e.g., surgery and injections) and non-invasive (e.g., massage, cervical mobilizations, trigger point therapy, and acupressure) in nature (Bogduk & Govind, 2009; Haldeman & Dagenais, 2001; Quinn et al., 2002; Schoensee et al., 1995). The goal of clinicians using non-invasive manual therapy techniques is to resolve patient complaints by treating the cervical spine as the primary source of CEH symptoms (Bogduk, 2004).

Non-invasive therapeutic techniques for CEH include cervical spine mobilization, massage, trigger point therapy, and acupressure (Bogduk & Govind, 2009; Haldeman & Dagenais, 2001; Quinn et al., 2002; Schoensee et al., 1995; Youdas et al., 1992). Researchers have demonstrated clinically significant reductions in headache intensity, frequency, and duration among patients treated with non-invasive techniques over at least a six-week treatment protocol (Bogduk & Govind, 2009; Haldeman & Dagenais, 2001; Quinn et al., 2002; Schoensee et al., 1995; Youdas et al., 1992). Although manual therapy techniques have been reviewed as effective management tools for CEH (Bogduk & Govind, 2009; Haldeman & Dagenais, 2001; Quinn et al., 2002; Youdas et al., 1992), no studies have specifically evaluated the effects of pain intensity changes and cervical range of motion after shorter treatment durations, such as a two-week treatment protocol. Conservative treatments that require extended durations to achieve significant results may motivate patients to seek faster remedies (e.g., medication) that perpetuate their condition by altering symptoms without addressing the underlying cause.

The MyoKinesthetic (MYK) System is an evaluation and treatment paradigm used to restore the central nervous system’s (CNS) communication with the musculoskeletal system to achieve allostasis. The MYK evaluation is designed to identify abnormalities in a patient’s static posture and connect those abnormalities to specific nerve root(s) via the associated myotome(s). The clinician then treats at the level of the identified myotome by using active and passive patient movements with a simultaneous external stimulus, similar to massage, to stimulate the communication pathways of the CNS.

The MYK System is theorized to decrease nociceptive firing that may cause or occur due to joint and tissue movement restriction (Smith & Bolton, 2013). The MYK system aims to create postural balance by treating the bilateral neuromuscular system along a specific nerve root. Specifically, for headaches, the MYK System utilizes additional classification beyond postural evaluation, including assessing headache pain and location. The MYK system, which helps the clinician determine the nerve root to be treated, offers a headache assessment table designed by Dr. Mike Uriarte (Uriarte, 2004). The location of headache-related symptoms in one or multiple areas (e.g., top of the head, sides of the head, front or back of the head, front of the head above the eyes, and back of the head no lower than the occiput) is used to determine which cervical nerve root may be affected. Currently, limited published research examines the effectiveness of the MYK headache treatment on headache-related pain (Moy, 2015).

The purpose of this case study was to examine the effects of the MYK system over two weeks when treating a patient classified with chronic CEH (i.e., occurring 15 days or more per month for longer than three months).

TABLE 1

The ‘Yes/No’ Cervical Nerve Root Assessment Chart

Nerve RootLocation of PainSpecial Characteristics
C1Anywhere on the head, this is determined when we do the ‘yes/no’ test.If their head is ‘rotated only,’ it is C1.  
C2Top of the head, sides of the head, front and back of the head. No lower than the occiput.  
C3In the eyes, between the eyes, behind the eyes, into the jaw or cheek area, top of the neck. 

Case Report

The patient, a thirty-three-year-old female, reported her main complaints were headache pain and neck discomfort off and on for over ten years, starting while she was in middle school.  A signed HIPAA and informed consent form were obtained before the initial evaluation and treatment. The patient’s prior history of significant injury included rotator cuff lesion and finger, foot, and toe fractures. The patient underwent shoulder arthroscopy to repair the rotator cuff three years prior. Still, since the headaches were present before and after the surgery, it was not believed to be a primary contributing factor. The patient’s contributing factors that coincided with her headache symptoms included sinusitis and bilateral numbness in her hands.  The patient also reported that she had missed significant events in her life because of her chronic headache pain. Her work-life was frequently disturbed; she required breaks often and was unable to stay focused on her tasks. In her own words, her ‘everyday active lifestyle was disrupted frequently’. 

The patient pursued multiple treatments and techniques over several years to relieve her headaches and neck discomfort but found little to no success. Some treatments positively impacted her condition for a short period but had not changed her condition long-term. These treatments and techniques included chiropractic care, medication, injections, essential oils, and physical therapy. Prescription pain medication and muscle relaxers were used as a last resort.  Over-the-counter medicines were used by the patient weekly as needed.

METHODS

Assessment

After obtaining a complete history and satisfying the inclusion/exclusion criteria (see Table 2), a physical examination was performed, consisting of cranial nerve and vertebral artery insufficiency testing, before the MYK ‘yes/no’ test and the MyoKinesthetic (MYK) full-body postural assessment.  Cranial nerve function tested normal, as did the vertebral artery performance.

Table 2

 Inclusion and Exclusion Criteria.

Inclusion CriteriaExclusion Criteria
-Pain projected to the forehead, orbital region, temples, ears, neck, or occipital region; -Pain with specific neck movements or sustained postures; -Complaints of palpable pain or discomfort/limitation of active or passive ROM.-Participants > 50 years old; -Positive Vertebral Artery Test; if positive, refer out  -If any analgesic or non-steroidal anti-inflammatory drugs (NSAIDs) were taken within the last 24 hours; -If the participant has an acute diagnosis of concussion or has not been released by a physician for full activity with no restriction from a concussion diagnosis

The MYK ‘yes/no’ test is used within the MYK System to determine resting head position. The patient stands with eyes closed and nods and shakes his/her head several times before coming to a comfortable resting position. The position of the head at rest is noted. Assessing cervical posture/imbalance with eyes closed may help to remove the visual input that the body uses to level itself with the horizon. In conjunction with the location of symptoms as outlined in Table 1, the ‘Yes/No’ Test is used to determine the cervical nerve root associated with the patient’s posture and symptoms. In this case, the patient’s cervical posture was visibly laterally flexed to the right. 

The MYK full-body postural assessment consists of the clinician evaluating the patient’s posture and stance, noting any imbalances when compared bilaterally and against postural norms (e.g., neutral).  In this case, clinical evaluation utilizing the MYK full-body postural assessment (Table 3) and clinician expertise demonstrated a C1-T1 dysfunction, with considerable postural imbalances associated with C6. The patient’s primary complaint was headache pain on the top of the head and temples with general neck discomfort. As outlined in Table 1, the C2 nerve root was identified as the affected nerve root using the headache treatment guidelines.

Pain-free active cervical ranges of motion (extension, flexion, and right/left rotation) were assessed using a goniometer with the patient’s eyes closed. At the initial examination, the patient had 53 degrees of pain-free active cervical extension and 45 degrees of pain-free active cervical flexion.  Pain-free active cervical rotation to the left and right was 60 degrees and 67 degrees, respectively.

Instrumentation

For patient-reported instruments to be most helpful in clinical practice and research, those with good psychometric properties and clinical applicability were utilized (Houts et al., 2020; Farrar et al., 2001). Instruments that were well-established in the literature and validated were selected to measure the impact of headaches in this case study.

The Headache Impact Test Questionnaire

The Headache Impact Test (HIT-6) is designed to assess the global impact of headaches on patients, measuring content areas such as pain, social-role limitations, cognitive functioning, psychological distress, and vitality (Houts et al., 2020). Nachit-Ouinekh et al. (2005) evaluated the global impact of episodic headaches in patients consulting general practitioners using the HIT-6 questionnaire and compared headache severity and quality of life. A comparison of the HIT-6 scores was conducted for each of the four sub-scores (i.e., functional, psychological, social, and therapeutic indices) against the French Qualité de Vie et Migraine (QVM) questionnaire (Nachit-Ouinekh et al., 2005). Scores range from “60 or more—headache has a severe impact on your life” to “49 or less—headache has little to no impact on your life” (Nachit-Ouinekh et al., 2005).

The Numerical Pain Rating Scale

The Numerical Pain Rating Scale (NPRS) is an 11-point numerical scale in which the clinician asks the patient to rate their pain verbally on a scale from 0 (no pain) to 10 (worst pain imaginable) (Farrar et al., 2001). In this study, average scores were calculated using the patient’s “current,” “best,” and “worst” pain scores, which were then compared to the post-treatment “current” pain score.

The Neck Disability Index

The Neck Disability Index (NDI) is a patient-reported, condition-specific functional status questionnaire that includes items related to pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping, and recreation. Out of a possible 50 points, a higher score indicates greater patient-perceived neck disability. A 5-point change on the index is considered a clinically important difference (Chan Ci En et al., 2009).

At the initial assessment, the patient reported an NPRS of 4/10, a HIT-6 score of 58, and an NDI score of 14/50. Measurements and outcomes were also collected at 30- and 60-day follow-ups.

The treatment of the C2 nerve root was determined based on the MyoKinesthetic (MYK) System’s “yes/no” test results. Treatment was performed following MYK System guidelines with the patient in a seated position. The clinician administered treatment using the MYK System parameters: passive movements were completed first, with the clinician passively moving the participant through each muscle’s range of motion (five times) while applying manual stimulus similar to massage to the muscles of the C2 myotome. Then, the participant actively moved (seven times) through the same range of motion while the clinician applied the same stimulus to the muscles. Once all muscles innervated by the C2 nerve root were treated bilaterally, treatment was complete. Treatments lasted approximately eight minutes on average and were conducted six times over two weeks, with 48 to 72 hours between each treatment.

RESULTS

After the final treatment, the pain reported on the NPRS was 5/10. The patient also completed the NDI and HIT-6, with scores of 15/50 and 54 points, respectively (see Table 4). Cervical range of motion (ROM) measurements were recorded in degrees and evaluated pre- and post-treatment. There were significant improvements in cervical extension ROM, with an increase of 7 degrees post-final treatment. A summary of ROM measurements is presented in Table 5.

The mean pain scores across the two weeks of treatment were not clinically significant compared to the NPRS minimally clinically important difference (MCID), which is defined as an average decrease of 2 points. In this case, the average decrease was only 0.25 points (Chan Ci En et al., 2009). However, daily NPRS results met the minimally clinically significant difference at the 30-day follow-up, with an average of 0 (Chan Ci En et al., 2009). Lastly, the patient’s postural examination changed between intake and discharge, as many imbalances were corrected within normal limits (see Table 3; Uriarte, 2004).

The patient reported a dramatic decrease in headache frequency over the two-week period, from experiencing a headache daily to only one every three days. By the end of the two-week treatment period, the patient noted that headache duration significantly decreased, lasting approximately 15 minutes compared to several hours or days before treatment. The patient also reported improved tolerance for physical activities she had previously been unable to perform, such as walking for extended periods, lifting weights, completing household tasks, and playing with her child. Disruptions at work were also greatly diminished, and the patient reported improved ability to focus on tasks with greater ease.

While the patient reported notable improvements, it is essential to analyze the raw data to form a proper conclusion. When evaluating follow-up scores, the findings suggest lasting improvements in multiple aspects of the patient’s life, including but not limited to neck function, perceived headache impact, pain levels, and range of motion. The follow-up scores are illustrated in Table 4.

DISCUSSION

The MyoKinesthetic (MYK) System elicited positive and lasting changes in this patient with frequent and intense cervicogenic headaches (CEH) over just two weeks of treatment. By the 60-day follow-up, the patient’s pain was nearly eliminated, and headache frequency had become rare. The patient also reported no headache-related pain or discomfort between treatments, which were spaced 48 to 72 hours apart. Improvements were observed in cervical flexion and right rotation, and the patient reported a significant enhancement in functional activities, allowing her to enjoy a more comfortable home life and a less painful work environment. The MYK System may be beneficial for other patients with CEH; however, research on its effectiveness remains limited, as is the case with other manual therapy techniques. Further studies are needed to determine why MYK may have been effective in treating this patient.

Manual therapy has been shown to decrease pain, improve function, and enhance quality of life in patients with musculoskeletal conditions, though its effectiveness varies among individuals (Uriarte, 2004). For example, massage therapy is commonly used to treat general pain complaints, yet some patients experience substantial relief while others show little to no improvement. Similarly, alternative treatment approaches, such as mobilizations with movement, may have been more or less effective in addressing the patient’s primary complaint. Treating patients with pain is inherently subjective, as each patient’s response is influenced by a combination of mental, physical, and emotional factors.

The MYK technique may extend its effects beyond conventional treatment boundaries. Patients may perceive MyoKinesthetic treatment as similar to joint mobilization and massage (e.g., pressure, squeezing, trigger point therapy). Neural mobilization may also occur as all tissues move through various ranges of motion. Some patients report a stretching or traction effect, while others describe experiencing a “pop” sensation, suggesting a possible manipulative effect. The MYK System is designed to be quick and efficient, requiring minimal space and exertion from the clinician (Moy, 2015).

Although limited research has explored manual therapy as a viable treatment for headaches, Smith and Bolton (2013) provided a compelling argument supporting its use. While acknowledging study limitations, their evaluation considered both postural and pain-related factors. Headaches related to stress, nerve irritation, or muscle spasms were subjectively identified, and chronic pain in the neck and upper trapezius region was also noted. MYK was used in this case to address the patient’s symptoms, and the treatment was beneficial. The systematic evaluation process within the MYK System highlighted neuromuscular imbalances, targeted their treatment, and raised the question of whether MYK could serve as an effective intervention for headaches (Uriarte, 2004).

A study by Moy (2015) applied the MYK System to a patient with complaints of neck pain, shoulder pain, hip pain, and headaches. Through a comprehensive assessment, the C8 nerve root was identified as the source of the patient’s symptoms. Following targeted MYK treatment, the patient experienced a significant reduction in pain, improved cervical range of motion, and enhanced quality of life after nine treatment sessions.

At the conception of the MYK System, a review of research addressing neuromuscular function and dysfunction was conducted. Understanding the neuromuscular system was fundamental to its development. Dr. Uriarte (2004) conceptualized the neuromuscular system as a “two-sided story,” emphasizing the necessity of bilateral treatment to address the root cause of pain rather than merely targeting the symptomatic area.

Furthermore, during MYK treatment, the body may perceive movement as normal and recognize the applied stimulus as non-threatening. This process allows patients to transition from painful to non-painful motion. A unique aspect of the MYK System is how treatment concludes. According to Dr. Uriarte (2004), posture serves as an external reflection of the neurological system. Before treatment, compensatory patterns may develop due to dysfunction and gravitational forces. Following treatment, the body and neurological system are expected to feel more balanced and better equipped to adapt to movement and gravity naturally.

Limitations

As with any attempted case study, limitations were present. Limitations included the following: 1) The treatment pressure may vary among treatments over the two weeks.  While the type of stimulus (stroking, tapping, massaging) may not matter, varying pressure has not been studied; therefore, the effects of pressure have not been determined.  This may be viewed as a limitation of the technique rather than a limitation of this study.  2) Reliability of goniometric measurement was not established before data collection, which may have created a limitation on reporting significant cervical ROM changes.  However, all measurements were taken in the same setting, patient position, and by the same clinician.  Validity and reliability of goniometric measures are usually established amongst clinicians, with multiple ROM measurements collected blindly over some time with the same subjects.  With there only being one patient and one clinician in this study, inter- and intra-reliability are lacking.  3) Although the patient was instructed not to take medication or have other treatments for headaches, the clinician cannot control what happens outside the clinic.  The patient did not report any other treatments or taking medication during the time of the study.

Further research should be conducted, exploring whether the muscles’ stimulation affects multiple participants with suspected cervicogenic headache during the acute stages of a CEH.  Other research should be conducted utilizing the MYK manual therapy treatment technique on different body regions to determine treatment effectiveness.  Another viable research topic would be comparing the specific nerve root treatment based on the location of headache pain (C1, C2, C3) compared to the location of dysfunction according to the MYK Upper Body assessment findings (C1-T1).    

CONCLUSIONS

MYK manual therapy helped this patient improve in their complaint of headache pain and frequency.  This study demonstrates that the MYK System headache treatment may be a practical treatment choice to reduce the intensity of patient-reported pain in patients with suspected cervicogenic headaches.  The treatment of cervical nerve root C2 from the MYK System created a clinically significant change in the participant’s perceived pain, including some results found after the 30-day and 60-day follow-ups.   

The question arises: Is MYK the most viable option for patients suffering from headache-related pain?  MYK is quick, easy, and presents as effective.  The treatment needs more research and discussion to support the idea that MYK is effective and helps validate more manual therapy techniques.  While MYK is not the only manual therapy technique available, it appears viable when assessing and treating patients. Overall, the changes in pain, intensity, and frequency observed in this study support the MyoKinesthetic System headache treatment along cervical nerve root C2 as a successful form of a non-invasive technique when treating cervicogenic headaches.

APPLICATIONS IN SPORT

For coaches, athletic trainers, and parents, understanding cervicogenic headaches (CEH) and their potential impact on athletes is crucial. Athletes, especially those involved in contact sports or repetitive motions, are at a higher risk for neck injuries that could lead to headaches. These headaches can affect an athlete’s performance and overall well-being, causing discomfort, limiting movement, and sometimes sidelining them from practice or competition.

As a coach or athletic trainer, recognizing the signs of CEH and addressing them early can make a significant difference in an athlete’s recovery and performance. Techniques such as cervical mobilizations, myofascial release, and other manual therapies can relieve, improve range of motion, and prevent long-term issues. By being proactive and incorporating strategies to address CEH, you can help athletes stay on track, reduce downtime, and support their physical function, ultimately enhancing their athletic experience and success. Parents, too, can play an important role by being aware of the symptoms and encouraging their athletes to seek timely treatment.

Acknowledgments

The authors declare no conflict of interest and did not receive payment for this study.

REFERENCES 

  1. Bogduk, N. (2001). Cervicogenic headache: Anatomic basis and pathophysiologic mechanisms. Current Pain and Headache Reports, 5(5), 382–386. https://doi.org/10.1007/s11916-001-0025-y
  2. Bogduk, N. (2004). The neck and headaches. Neurologic Clinics, 22(1), 151–171. https://doi.org/10.1016/j.ncl.2003.11.006
  3. Bogduk, N., & Govind, J. (2009). Cervicogenic headache: An assessment of the evidence on clinical diagnosis, invasive tests, and treatment. The Lancet Neurology, 8(10), 959–968. https://doi.org/10.1016/S1474-4422(09)70209-9
  4. Sjaastad, O., Fredriksen, T. A., & Pfaffenrath, V. (1998). Cervicogenic headache: Diagnostic criteria. Headache: The Journal of Head and Face Pain, 38(6), 442–445. https://doi.org/10.1046/j.1526-4610.1998.3806442.x
  5. The International Classification of Headache Disorders, 3rd edition. (2018). Cephalalgia, 38(1), 1–211. https://doi.org/10.1177/0333102417738202
  6. Yang, M., Rendas-Baum, R., Varon, S. F., et al. (2010). Validation of the Headache Impact Test (HIT-6™) across episodic and chronic migraine. Cephalalgia, 31(3), 357–367. https://doi.org/10.1177/0333102410379890
  7. Quinn, C., Chandler, C., & Moraska, A. (2002). Massage therapy and frequency of chronic tension headaches. American Journal of Public Health, 92(10), 1657–1661. https://doi.org/10.2105/AJPH.92.10.1657
  8. Haldeman, S., & Dagenais, S. (2001). Cervicogenic headaches. The Spine Journal, 1(1), 31–46. https://doi.org/10.1016/S1529-9430(01)00017-2
  9. Schoensee, S. K., Jensen, G., Nicholson, G., et al. (1995). The effect of mobilization on cervical headaches. Journal of Orthopaedic & Sports Physical Therapy, 21(4), 184–196. https://doi.org/10.2519/jospt.1995.21.4.184
  10. Youdas, J. W., Garrett, T. R., Suman, V. J., et al. (1992). Normal range of motion of the cervical spine: An initial goniometric study. Physical Therapy, 72(11), 770–780. https://doi.org/10.1093/ptj/72.11.770
  11. Hall, T. M., Robinson, K. W., Fujinawa, O., et al. (2008). Intertester reliability and diagnostic validity of the cervical flexion-rotation test. Journal of Manipulative and Physiological Therapeutics, 31(4), 293–300. https://doi.org/10.1016/j.jmpt.2008.03.007
  12. Uriarte, M. (2004). MyoKinesthetic system upper body training manual. MyoKinesthetic Institute.
  13. Moy, B. (2015). Case study detail – The MyoKinesthetic Institute (MYK). MyoKinesthetic Institute. Retrieved August 18, 2021, from https://www.myokinesthetic.com/case-studies/the-treatment-of-c8-with-manual-therapy
  14. Houts, C. R., Wirth, R. J., McGinley, J. S., et al. (2020). Determining thresholds for meaningful change for the Headache Impact Test (HIT‐6) total and item‐specific scores in chronic migraine. Headache: The Journal of Head and Face Pain, 60(10), 2003–2013. https://doi.org/10.1111/head.13950
  15. Nachit-Ouinekh, F., Dartigues, J. F., Henry, P., et al. (2005). Use of the Headache Impact Test (HIT-6) in general practice: Relationship with quality of life and severity. European Journal of Neurology, 12(3), 189–193. https://doi.org/10.1111/j.1468-1331.2004.00929.x
  16. Farrar, J. T., Young, J. P., LaMoreaux, L., et al. (2001). Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain, 94(2), 149–158. https://doi.org/10.1016/S0304-3959(01)00349-9
  17. Chan Ci En, M., Clair, D. A., & Edmondston, S. J. (2009). Validity of the Neck Disability Index and Neck Pain and Disability Scale for measuring disability associated with chronic, non-traumatic neck pain. Manual Therapy, 14(4), 433–438. https://doi.org/10.1016/j.math.2008.07.005
  18. Smith, J., & Bolton, P. S. (2013). What are the clinical criteria justifying spinal manipulative therapy for neck pain? A systematic review of randomized controlled trials. Pain Medicine, 14(4), 460–468. https://doi.org/10.1111/pme.12081
  19. Norkin, C. C., White, D. J., Torres, J., et al. (2016). Measurement of joint motion: A guide to goniometry (5th ed.). F.A. Davis Company.

APPENDIX

Table 3

MYK Postural Assessment (pre/post)

Table 4

Patient Reported Outcomes

 NDIHIT-6NPRS
ASSESSMENTScoreRankingScoreRankingPre- ScorePost- ScoreMean of  Raw
Initial14/50Mild58Substantial433.75
Discharge15/50Moderate54Some754
Mean__57.6Substantial–––
30-Day8Mild46Little to no impact––0
60-Day5Mild38Little to  no impact––.666

Table 5

Goniometric measurement mean normative data for cervical range of motion taken from Norkin et al.

Cervical Range of Motion
MovementNormative DataPre-treatmentPost-treatment (change)30-Day Follow Up60-Day Follow Up
Flexion40° ± 1245°40° (-5°)47.3°46°
Extension50° ± 1453°60° (7°)41.6°37°
Left Rotation49° ± 953°54.6° (1.6°)55.6°51°
Right Rotation51° ± 1160°61.6° (1.6°)58.6°62°
2025-10-08T12:16:04-05:00April 15th, 2026|Concussions, General, Research, Sports Health & Fitness, Sports Medicine|Comments Off on A Manual Therapy Treatment for Headache Pain
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Supplemental lessons to the Peak Health and Performance curriculum: Nutritional considerations for injury, energy management, and gastrointestinal issues

Authors: Tyler B. Becker12, Ronald L. Gibbs, Jr2

1Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, USA

2Michigan State University Extension, Health and Nutrition Institute, Michigan State University, East Lansing, Michigan, USA

 

Corresponding Author:

Tyler B. Becker, PhD, CSCS

469 Wilson Road, Room 125

East Lansing, MI 48824

[email protected]

517-353-3338

Tyler B. Becker, PhD, CSCS is an Associate Professor of Nutritional Sciences at Michigan State University in East Lansing, MI. His research interests focus on sports nutrition practices and strategies in youth athletes and higher education andragogy.

Ronald L. Gibbs, Jr, PhD, MCHES is currently a Program Evaluation Specialist for Michigan State University in East Lansing, MI. His research interests focus on coach and athlete education, long-term athlete development (LTAD), psychosocial aspects of sports and physical activity, adolescent nutrition and physical activity behavior change through sport participation, sports performance, and reducing childhood obesity.

ABSTRACT 

Youth sports injuries are quite common in sport and have several negative consequences, including healthcare costs, loss of playing time, and producing mental stress. Nutritional strategies have been suggested to improve recovery from sports-related injuries. The Peak Health and Performance (PHP) youth-sports curriculum was developed to use sport to promote healthy eating behaviors. Six additional lessons on nutrition for recovery from injury, energy management, and gastrointestinal issues have been added as addendums to PHP. Lesson A discusses the importance of key nutrients (eg., protein, complex carbohydrates, unsaturated fatty acids, water) for promoting tissue healing following an injury. Lesson B describes several micronutrients and the possible role of nitrates for aiding in injury recovery. Lesson C discusses the implications of low energy availability, including how to identify and prevent it. In Lesson D, several nutritional strategies for addressing mild traumatic brain injuries are explored. Lesson E discusses the importance of sleep for injury recovery and describes nutritional strategies for improving sleep quality. The final lesson (Lesson F) describes various gastrointestinal issues encountered in sport and how to prevent them. Future research will examine youth athlete knowledge of nutritional strategies for recovering from a sports-related injury following these lessons.

KEYWORDS: adolescent sports; sports nutrition; injury management

INTRODUCTION 

Sports-related injuries are a significant concern among adolescent athletes, with prevalence rates ranging from 34.1% to 65% (2). Certain groups, including female athletes, obese athletes, and those participating in contact sports, are at particularly high risk.  In the US, the rate of injuries in sports, recreation, and leisure activities is 117.1 per 1000 children and adolescents aged 12-17 years of age (57). These injuries impose substantial financial burdens; for example, over a 5-year period in Florida, inpatient care costs for pediatric sports injuries totaled $24.55 million, while emergency care expenses reached $87 million (61). Beyond the economic impact, sports-related injuries also incur both physical and mental challenges to the athlete, including lost playing time, with female athletes averaging 10 days of missed competition per injury (5). This contributes to social isolation and depressive symptoms in adolescent athletes during recovery (63). In addition, gastrointestinal (GI) problems, including diarrhea, vomiting, and abdominal injuries are common place among athletes (12,73), and can contribute to decreases in performance and a loss of playing time (39). Given these multifaceted challenges, there is a critical need to optimize injury prevention and rehabilitation strategies to support young athletes’ physical and psychological well-being.

Proper nutritional intake plays a critical role in injury prevention and rehabilitation among youth athletes (3). In addition to supporting overall health and well-being, adequate nutrition is essential during adolescence–a period marked by rapid growth and development–and contributes to athletic performance and post-workout recovery (15, 66). Despite its importance, many adolescent athletes demonstrate a lack of knowledge regarding both general and sport-specific nutritional practices (6).  A recent systematic review by Hulland et al. (2023) revealed that adolescent athletes are more familiar with general than sport-specific dietary strategies (32), while Gibbs and Becker (2025) found that both male and female adolescent athletes scored below 50% on assessments covering both areas (24). These findings underscore a significant gap in nutritional literacy among youth athletes, indicating the need for targeted education to optimize their health development and athletic outcomes.

Several nutritional strategies have emerged highlighting the importance of it for injury rehabilitation primarily in adult athletes (26, 54, 65). For example, kilocaloric and protein needs often increase following injury due to a need for recovery and maintenance of lean body mass resulting from disuse (58, 65). However, the application of nutritional strategies for recovering from injury for youth athletes remains understudied. Alcock et al. (2024) offered a comprehensive overview of injury rehabilitation strategies for youth, indicating practical applications; however there remains a critical gap in understanding how adolescent athletes perceive and apply nutrition during recovery (3). To date, no research has directly examined youth athletes’ knowledge of nutrition for injury rehabilitation, but existing evidence suggests they are likely deficient in this area as well (46). Research suggests that poor food literacy and nutrition knowledge could theoretically contribute to increased injury risk (3, 15). This reinforces the urgency of developing age-appropriate interventions that address both performance and recovery nutrition, particularly in the context of injury.

The Peak Health and Performance (PHP) curriculum was designed from a collaboration by faculty and staff at Michigan State University, Division of Sports and Cardiovascular Nutrition, College of Osteopathic Medicine, East Lansing, MI and Spartan Performance Training, East Lansing, MI (25). This curriculum incorporates various sports nutrition best practices from several areas of literature providing sports nutrition recommendations (17, 66, 69). Fruit and vegetable intake significantly increased in 290 children and adolescents who completed the PHP curriculum (4). Due to the success of the program in modifying nutrition behaviors, additional lessons were created to educate youth on nutritional strategies for injury recovery, energy management, and managing GI issues. These topics include nutritional strategies for musculoskeletal and mild traumatic brain injury (mTBI) recovery, and other nutritional considerations around injury risk and recovery including sleep, low energy availability (LEA), and GI issues. This manuscript describes the rationality and creation of these addendum lessons for the PHP curriculum.

LESSON CONTENT

The original PHP curriculum consists of six lessons labeled as: Lesson 1- Nutrition Basics; Lesson 2- Athletes Performance Plates; Lesson 3- Timing of Intake; Lesson 4- Hydration, Energy Drinks, and Sugary Beverages; Lesson 5- Convenience Foods; and Lesson 6- More Than a Game (25). Further information on PHP learning objectives and topics inclusion can be found in Gibbs & Becker (25). The new additional lessons and their learning objectives can be found in Table 1.  These additional lessons are meant to serve as their own lesson series, a single lesson session, or as supplemental lessons to the original PHP lessons.

Table 1.
Additional Lessons for the Peak Health and Performance Curriculum: Learning Objectives
LessonLearning Objectives
A: Macronutrients for Injury Rehabilitation • Explain the four phases of an injury
• Understand the importance of consuming enough calories following an injury
• Explain why protein is needed during the health process and recall amounts needed
• Explain the role that carbohydrates have during the healing process
• Describe what role unsaturated fatty acids, such as omega-3s, have while healing an injury.
• Understand the importance of water during the healing process
B: Micronutrients for Injury Rehabilitation• Explain the importance of choosing food sources of vitamins and minerals over dietary supplements
• List and understand the roles that vitamins A, C, D, and E have in injury healing
• Identify good food sources of vitamins A, C, D, and E
• List and understand the roles that calcium, zinc, and iron have in injury healing
• Identify good food sources of calcium, zine, and iron
• Explain why foods high in nitrates may promote injury healing and identify good food sources of them
C: Low Energy Availability• Explain what low energy availability is
• Identify what causes low energy availability
• Understand how low energy availability negatively impacts performance and recovery
• Explain how low energy availability may lead to other negative health outcomes
• Recognize the symptoms of low energy availability
• Describe prevention and treatment strategies for low energy availability
D: Nutrition for Head Injuries• Explain what happens during a head injury in sport
• List the different phases of concussion recovery
• Explain the benefits of creatine, magnesium, and flavonoids for head injury recovery
• Identify good food sources of creatine, magnesium, and flavonoids
• Identify other nutritional considerations to have when recovering from a head injury
E: Nutrition and Sleep for Injury Reduction and Recovery• Explain why sleep is important for performance and reducing and healing injuries
• Identify how much sleep an athlete should be getting each night
• Explain the benefits of melatonin and serotonin rich foods for improving sleep quality
• Identify other nutrients of interest that are related to sleep quality
• Identify foods to avoid prior to sleep
• List strategies to set up an ideal bedtime routine
F: Gastrointestinal Issues and Sport• Understand how vomiting and nausea symptoms may appear during practice and sport
• Provide strategies to reduce vomiting and nausea symptoms during practice and sport
• Explain how diarrhea can happen during practice and sport
• Identify strategies to prevent diarrhea during practice and sport
• Explain how probiotics and prebiotics are important for gut health

Each of these six lessons will be discussed in detail in the next section. These supplemental lessons were created in a manner to instruct participants to refer back to the original lessons for further information.

Lesson A: Macronutrients for Injury Prevention

This lesson begins by describing how musculoskeletal injuries heal and the importance of proper caloric intake and macronutrients during recovery from sports-related injuries. Each macronutrient is then highlighted to show its main role in providing both energy and nutritional needs to promote recovery. Macronutrient roles and responsibilities are described in detail in PHP Lesson 1 of the original curriculum (25).

Caloric Intake: The following section of the lesson describes the importance of meeting kilocalorie (kcal) needs to help heal an injury. Research on adult athletes suggest increasing kcal consumption by 10-15% during injury and recovery (58). Additionally, to offset sarcopenia in adults resulting from injury and disuse, energy intake should be between 25-40 kcal/kg of bodyweight per day (54). Independent of injury status, growth and development demands of children aged 9 and up typically require 60-65 kcal/kg of bodyweight per day (21). Taking energy needs during injury into account, coupled with normal demands for growth and development (21), an injured adolescent would need slightly more than the recommended 60-65 kcal/kg of bodyweight per day.

Protein: Following injury, protein requirements are significantly elevated to offset bodily stress incurred from the injury (65). Additionally, protein intake helps offset muscle atrophy due to disuse (47). Protein requirements for adult athletes and recreationally active adults is between 1.2 to 2.0 g/kg of bodyweight per day (69), with protein recommendations for adolescent athletes being in a similar range (15, 41). Following injury, it is suggested to increase daily intake of protein to 2.0 to 3.0 g/kg of bodyweight in athletic adults (65), which likely suffices for protein requirements for adolescent athletes.

Carbohydrates: Carbohydrates can provide a  source of energy while healing through an injury (65), and aid in muscle adaptations and recovery (69). Due to a decrease in the amount of high-intensity exercise that can be performed while injured, carbohydrate needs are not as large as what is needed in an uninjured athlete (65). Thus, to meet demand while recovering from an injury, up to 60% of daily kcals should come from carbohydrates (65), with an emphasis on complex carbohydrates.  Additionally, fatty acids are important in the recovery process as they synthesize several hormones and aid in the absorption of several vitamins (3,  27). Unsaturated fatty acids, such as omega-3 fatty acids may reduce inflammation, thereby making their need instrumental during the recovery process (27). It is recommended to consume good sources of omega-3 fatty acids including fatty fish, walnuts, flaxseed, and avocado, which this lessons includes as suggested food sources (27, 65).

Fluid Intake: Hydration for performance is covered in Lesson 4 of the original PHP, but in this lesson, it is explored in more detail pertaining to injury risk and recovery. Over half of US children are inadequately hydrated (37), and being in this state can increase risk of injury and prolong recovery (10). Muscles on average are 75% water with bones comprising 25% of it, suggesting that a lowered consumption of it could further exacerbate healing of injuries to these structures (27). Males aged 9 to 13 years need at least 8 cups of fluid per day, while females of the same age need at least 7 cups per day (34). Adolescent males aged 14 to 18 years of age, need at least 11 cups of fluid per day, while females of the same age need 8 cups. Thus, it could be hypothesized that an injured youth athlete should strive to meet and exceed these recommendations for fluid consumption.

Lesson B: Micronutrients for Injury Rehabilitation

Lesson B highlights the importance of specific micronutrients that provide a key role in injury rehabilitation (3, 26). Consuming adequate nutrients, including micronutrients, from whole food sources, is a major goal of the PHP curriculum (21). This lesson begins with a discussion on the concerns with the use of dietary supplements to meet micronutrient recommendations such as issues with regulation (20), and possible contamination (40). Each section of the lesson describes how the micronutrient of interest is implicated in the recovery process, how much is needed, other important functions it provides in the body, and suggested foods that are good sources for the micronutrient of interest.

Vitamin D and Calcium: As summarized in Alcock et al. (2024) micronutrients of interest for bone injury rehabilitation include vitamin D and calcium (3). Calcium is needed to increase bone mineral density and bone remodeling such as when following an injury (27). Vitamin D is needed for calcium absorption and maintenance. Children and adolescents between 9 and 18 years old, need 1,300 mg of calcium every day (23). Adolescents between 14- and 18-years old need at least 15 mcg (600 IUs) of vitamin D daily. Food sources of calcium listed in the lesson include milk, yogurt, salmon, fortified fruit juice, and collard greens (27). Good food sources of vitamin D suggested in the lesson includes salmon, fortified milk, tuna, and cashews.

Zinc and Iron: Other micronutrients of interest for muscle injury also include zinc and iron (3). Zinc and iron are both trace minerals that have several important functions in the human body (27). Zinc is involved in hundreds of functions in the body, such as involvement in DNA synthesis and wound healing, and immune system function (27). Zinc is needed for protein synthesis and iron is needed for the transport of oxygen to several tissues in the body which would increase healing (27). Youth aged 9 to 13 years, need 8 mg of zinc per day (23). Male adolescents aged 14-18 years of age need 11 mg of zinc per day, while females of the same age require 9 mg each day.  Children aged 9-13 years of age need 8 mg of iron per day (23). Males aged 14-18 years of age need 11 mg of iron per day, and females of the same age need 15 mg per day. Good sources of zinc include dark meat, legumes, shrimp, and nuts (27). Good food sources of iron includes dark meat, and also spinach and cashews.

Vitamins A, C, and E: Vitamin C plays a pivotal role in the synthesis of collagen (3). Similar to vitamin C, vitamin A aids in collagen formation, specifically the laying down of new collagen (65). Vitamin E can reduce muscle breakdown and promote muscle repair (27). Each of these vitamins can reduce oxidative stress and inflammation and improve tissue healing (27). Children aged 9 to 13 years old need 1,200 mg of vitamin C every day, and adolescents aged 14 to 18 years old, need 1,800 mg per day (23). Good food sources of vitamin C include kiwis, green peppers, strawberries, and cantaloupe (27). Youth aged 9-13 years need 600 mcg of retinol activity equivalents (vitamin A) per day, while adolescents aged 14-18 years need 600 mcg of retinol activity equivalents each day (23). Youth aged 9-13 years of age need 11 mg of vitamin E per day, while adolescents over the age of 14 need 15 mg per day (23). Dietary sources of vitamin A include sweet potatoes, pumpkins, spinach, and squash, while good sources of vitamin E include sunflower seeds, apricots, avocados, and almonds (65).

Although not a micronutrient, eating foods high in nitrates, like beets, could theoretically help heal an injury (76). About 20% of the nitrates consumed in food is converted to nitrite by bacteria found in the oral cavity (76). In turn, the stomach transforms this nitrite into nitrous oxide which can cause vasodilation. Thus, more oxygen and nutrients are transported to the injured area, supporting the healing process. A recent systematic review examined nine studies and concluded that short-term consumption of beetroot may accelerate the recovery of muscle soreness and various functional markers due to its antioxidant and inflammatory properties likely exerted by its nitrate content and several phenolic compounds (60). Therefore, it could be assumed that consuming foods high in nitrates and phenolic compounds could expedite the injury healing process. Aside from beets, good food sources of nitrates include spinach, radishes, celery, and rhubarb (36).

Lesson C: Low Energy Availability

Energy availability is the amount of energy available after energy expenditure, that is used for bodily functions (9). Thus, LEA is the state of inadequate energy intake relative to energy expenditure (9) and the prevalence for LEA in athletes ranges from 22% to 58% in a given sport (44). LEA can lead to several negative impacts on performance including decreased muscular strength, decreased endurance performance, and decreased responses to training responses and adaptations (50, 70). Additionally, there is an increased injury risk with LEA (29,  56).

The next section of this lesson discusses how LEA can negatively impact the growth and development of a child or adolescent, potentially resulting in poor bone health, delayed puberty, short stature, and menstrual irregularities (15). It also highlights several signs and symptoms felt by an athlete that could indicate LEA (9, 70). 

LEA, with or without the presence of an eating disorder, is a characteristic of the Female Athlete Triad, which is a condition that also includes decreased bone mineral density, and menstrual dysfunction (53, 59). The concept of Relative energy deficiency in sport (RED-S) expands upon the Female Athlete Triad by recognizing a broader range of health consequences including disruptions to the endocrine system, immune system, and cardiovascular health (9). Raising awareness of these signs and symptoms is essential, especially given that knowledge of LEA remains low among both athletes and coaches (44). The lesson concludes with evidence-based strategies to prevent LEA, as well as treatment options to address its underlying causes (9).

Lesson D: Nutrition for Head Injuries

This lesson discusses various nutritional considerations to assist in the healing process for someone who has had a concussion, or other types of mTBI (22, 62). Current concussion rates in youth sports are 4.17 cases per 10,000 athlete exposures (38). There are several nutritional aspects that may support brain health among those recovering from mTBIs (22, 62). Although several macronutrients are considered nutrients of interest during this process (22, 62), this lesson discusses other nutrients and micronutrients (aside from those discussed in previous lessons) that may have a place while recovering from a mTBI, including creatine, magnesium, and flavonoids.

Creatine: Creatine is a compound that is formed in protein metabolism and works to recycle adenosine triphosphate (ATP) for energy metabolism (42). It has been shown that creatine content in the brain is diminished after a mTBI, and increasing its intake could maintain ATP levels in the brain (1, 65). This could help offset injury sustained from the mTBI, such as decreasing protease activation that degrades axon structures (1). Good food sources of creatine listed in this lesson includes lean red meats, fatty fish, pork, and wild game (72). 

Magnesium: Magnesium is a trace mineral that has several functions within the body (27). In the brain, magnesium is involved in efficient nerve signaling and maintaining the blood brain barrier (45). Following a mTBI, magnesium levels decrease in the brain (67), and low magnesium levels have been associated with neuroinflammation and neurodegeneration, including several diseases such as Alzheimer’s and Parkinson’s diseases (67). Research has revealed that magnesium supplementation can reduce concussion symptoms in adolescents following injury (67). Youth aged 9 to 13 years of age need 240 mg of magnesium per day (23). Older adolescent, males aged 14-18 years of age need 410 mg or magnesium per day while their female counterparts need 360 mg per day. Good food sources of magnesium include almonds, cashews, peanut butter, and spinach (27).

Flavonoids: Lastly, flavonoids are phytochemicals found in many fruits and vegetables, that have anti-inflammatory and antioxidant effects, which may reduce swelling after a mTBI (28). Blueberries contain high amounts of flavonoids including anthocyanins, which contribute to the blueberry’s dark color (11). Anthocyanins could lower brain inflammation and stress caused by mTBI (30). Laboratory studies have shown beneficial effects from blueberry supplementation on various cognitive performance outcomes and symptoms following a mTBI (43, 68). Therefore, consuming foods high in flavonoids, including blueberries, could offer a benefit for healing from a head injury.

This lesson concludes with additional nutritional considerations for those recovering from a mTBI. For example, it is suggested to eliminate the consumption of caffeine following a mTBI (65). Other suggestions include taking note of any foods or drinks that cause vomiting or feelings of nausea, and reducing their consumption for a period of time while mTBI symptoms decrease (72).

Lesson E: Nutrition and Sleep for Injury Reduction and Recovery

This lesson highlights the importance of sleep for performance and injury recovery (19, 49). Youth athletes not getting enough sleep are 1.7 times more likely to get injured (52). School-aged children need 9-11 hours of sleep each night, while teenagers need 8-10 hours of sleep per night (31). It is likely an injured athlete should aim for the upper amount of sleep needed per day. Currently, adolescents aged 13-18 years of age are getting on average 7.7 hours of sleep per night, slightly less than the minimum amount needed (48). Several nutrients have been identified that can naturally aid in hormone regulation associated with sleep (55).

Melatonin: Melatonin is a hormone secreted by the pineal gland that is involved in circadian rhythm and increases total sleep time and may reduce time to fall asleep (13, 55). It is found naturally in several foods including tart cherries (18, 51). In addition, tart cherries include other constituents that have anti-inflammatory and antioxidant effects, which may aid in sleep and recovery (8). Other foods with a high melatonin content include milk, pineapples, oranges, and bananas (18, 55).

Serotonin: Serotonin is another hormone involved in sleep by synthesizing hypogenic substances that influence sleep quality (7, 55). Kiwi fruits are a good source of serotonin and contain several minerals, dietary fiber, and phytochemicals that also may aid in sleep (18, 55).

This section of the lesson also includes other nutritional considerations for quality sleep. For example, some foods that contain caffeine, can make it difficult to fall asleep and the recommendation is to reduce or eliminate its intake closer to bedtime (33). This lesson concludes with tips on how to establish an effective sleep routine such as minimizing screen time before it (33).

Lesson F: Gastrointestinal Issues and Sport

This lesson addresses common GI issues encountered in sport and concludes with practical applications for maintaining gut health.

Nausea and Vomiting: Nausea and vomiting are frequent complaints among athletes across various disciplines (77). These symptoms may result from elevated levels of norepinephrine reducing splanchnic blood flow to the gut, delayed gastric emptying, or increased production of gastric bile acids (77). This lesson outlines several risk factors that may contribute to these symptoms along with simple strategies to help prevent them.

Diarrhea: Diarrhea is a common condition experienced by athletes, particularly among endurance athletes (77). Proposed mechanisms include the secretion of vasoactive intestinal peptide which relaxes smooth muscle in the digestive system (35), and changes in gut motility (77). Many of the risk factors associated with diarrhea overlap with those linked to nausea and vomiting. This section concludes with evidence-informed approaches for minimizing the risk of diarrhea during training and competition.

Heartburn: Heartburn is another GI issue sometimes encountered by athletes during exercise and sport and can be caused by increased abdominal pressure, changes in posture, and changes in exercise intensity (74). Additionally, consuming large meals prior to exercise, not being properly hydrated, and having high levels of stress or anxiety can also trigger heartburn. Chronic heartburn could be caused by gastroesophageal reflux disease or GERD (74). This section provides strategies to prevent heartburn during practice or a game, with an emphasis on taking note of such foods that sometimes cause heartburn in an individual.

This lesson concludes by discussing several strategies to maintain gut health and gut microbiota which may impact immunological function and thus injury risk and recovery from them (75). Rationale for its inclusion within this lesson is from the US Olympic & Paralympic Committee sports nutrition handout on nutrients for GI injury (71). Consuming foods high in probiotics may maintain digestion and absorption while also preventing several GI issues described in this lesson (71). Prebiotic fibers are a type of fermentable fiber that stimulates intestinal bacteria growth and activity (64). In addition, prebiotic fiber consumption is associated with several other benefits including increasing the absorption of calcium, improving cognitive health, and reducing risk of some diseases (14). Therefore, it is important to incorporate prebiotic fibers into one’s diet.

CONCLUSIONS

Nutrition is a cornerstone of health and performance for adolescent athletes not only supporting their growth and development but also their ability to train, compete, and recover effectively (15). Integrating sound nutrition practices into youth athlete development programs is essential for promoting lifelong well-being and optimal athletic potential (16). In addition to enhancing performance, proper nutrition can play a key role in preventing injuries and accelerating recovery when injuries occur (3). To emphasize these critical areas, several new lesson have been added as targeted addendums to the PHP curriculum (25). When combined with the original PHP content, these additions aim to strengthen both general and sport-specific nutrition behaviors, equipping young athletes with the knowledge and habits needed to thrive on and off the field.

Following an injury, it is important to consume adequate kcals from protein, carbohydrates, and unsaturated fatty acids, along with being properly hydrated to facilitate recovery (3). Emphasizing certain micronutrients from food may also improve recovery from injury (3). Additionally, nutritional support is needed for athletes recovering from an mTBI (65). LEA is a common problem in youth sports and understanding its consequences and how to prevent it are important for reducing injury risk (9). Getting adequate sleep is important not only for athletic performance, but also injury prevention and healing from an injury (19, 49). Although not a direct injury caused by sport, GI issues can occur during it, and can be prevented using evidence-based nutritional strategies (77). Next steps are to examine adolescent knowledge of nutritional best practices for recovering from sports-induced injuries.

APPLICATIONS IN SPORT
These supplemental lessons are to serve as adjunct lessons to the PHP curriculum and to provide youth athletes with knowledge on injury management and other sports nutrition topics not otherwise discussed in athletic circles. Additionally, the hope is to encourage further research in this understudied area and add to the growing body of literature examining nutrition practices for injury management in youth athletes.

REFERENCES 

1. Ainsley Dean, P. J., Arikan, G., Opitz, B., & Sterr, A. (2017). Potential for use of creatine supplementation following mild traumatic brain injury. Concussion, 2(2), Cnc34. https://doi.org/10.2217/cnc-2016-0016

2. Al-Qahtani, M. A., Allajhar, M. A., Alzahrani, A. A., Asiri, M. A., Alsalem, A. F., Alshahrani, S. A., & Alqahtani, N. M. (2023). Sports-related injuries in adolescent athletes: A systematic review. Cureus, 15(11), e49392. https://doi.org/10.7759/cureus.49392

3. Alcock, R., Hislop, M., Vidgen, H. A., & Desbrow, B. (2024). Youth and adolescent athlete musculoskeletal health: Dietary and nutritional strategies to optimise injury prevention and support recovery. Journal of Functional Morphology and Kinesiology, 9(4). https://doi.org/10.3390/jfmk9040221

4. Becker, T. B., & Gibbs, R. L. (2024). Changes in nutrition, food safety, and physical activity behaviors: A comparison between the Peak Health and Performance and Teen Cuisine Curricula. Journal of Human Sciences and Extension, 12(3), 10.

5. Beech, J., Jones, B., Hughes, T., & Emmonds, S. (2024). Injury profile in youth female athletes: A systematic review and meta-analysis. Sports Medicine, 54(5), 1207-1230. https://doi.org/10.1007/s40279-023-01988-w

6. Bird, S. P., & Rushton, B. D. (2020). Nutritional knowledge of youth academy athletes. BMC Nutrition, 6, 35. https://doi.org/10.1186/s40795-020-00360-9

7. Cespuglio, R. (2018). Serotonin: its place today in sleep preparation, triggering or maintenance. Sleep Medicine, 49, 31-39. https://doi.org/https://doi.org/10.1016/j.sleep.2018.05.034

8. Chai, S. C., Davis, K., Zhang, Z., Zha, L., & Kirschner, K. F. (2019). Effects of tart cherry juice on biomarkers of inflammation and oxidative stress in older adults. Nutrients, 11(2). https://doi.org/10.3390/nu11020228

9. Charlton, B. T., Forsyth, S., & Clarke, D. C. (2022). Low energy availability and relative energy deficiency in sport: What coaches should know. International Journal of Sports Science & Coaching, 17(2), 445-460. https://doi.org/10.1177/17479541211054458

10. Chodkowski, J. (2024). The role of nutrition and hydration in injury prevention and recovery: A review. Journal of Educcation Health and Sport, 71, 56117.

11. Conti, F., McCue, J. J., DiTuro, P., Galpin, A. J., & Wood, T. R. (2024). Mitigating traumatic brain injury: A narrative review of supplementation and dietary protocols. Nutrients, 16(15), 2430. https://www.mdpi.com/2072-6643/16/15/2430

12. Costa, R. J. S., Snipe, R. M. J., Kitic, C. M., & Gibson, P. R. (2017). Systematic review: exercise-induced gastrointestinal syndrome-implications for health and intestinal disease. Aliment Pharmacolology and Therapeutics, 46(3), 246-265. https://doi.org/10.1111/apt.14157

13. Costello, R. B., Lentino, C. V., Boyd, C. C., O’Connell, M. L., Crawford, C. C., Sprengel, M. L., & Deuster, P. A. (2014). The effectiveness of melatonin for promoting healthy sleep: a rapid evidence assessment of the literature. Nutrition Journal, 13, 106. https://doi.org/10.1186/1475-2891-13-106

14. Davani-Davari, D., Negahdaripour, M., Karimzadeh, I., Seifan, M., Mohkam, M., Masoumi, S. J., Berenjian, A., & Ghasemi, Y. (2019). Prebiotics: Definition, types, sources, mechanisms, and clinical applications. Foods, 8(3). https://doi.org/10.3390/foods8030092

15. Desbrow, B. (2021). Youth athlete development and nutrition. Sports Medicine, 51(Suppl 1), 3-12. https://doi.org/10.1007/s40279-021-01534-6

16. Desbrow, B., Burd, N. A., Tarnopolsky, M., Moore, D. R., & Elliott-Sale, K. J. (2019). Nutrition for special populations: Young, female, and masters athletes. International Journal of Sport Nutrition and Exercise Metabolism, 29(2), 220-227. https://doi.org/10.1123/ijsnem.2018-0269

17. Desbrow, B., McCormack, J., Burke, L. M., Cox, G. R., Fallon, K., Hislop, M., Logan, R., Marino, N., Sawyer, S. M., Shaw, G., Star, A., Vidgen, H., & Leveritt, M. (2014). Sports Dietitians Australia position statement: sports nutrition for the adolescent athlete. International Journal of Sport Nutrition and Exercise Metabolism, 24(5), 570-584. https://doi.org/10.1123/ijsnem.2014-0031

18. Doherty, R., Madigan, S., Warrington, G., & Ellis, J. (2019). Sleep and nutrition interactions: Implications for athletes. Nutrients, 11(4). https://doi.org/10.3390/nu11040822

19. Dwivedi, S., Boduch, A., Gao, B., Milewski, M. D., & Cruz, A. I. J. (2019). Sleep and injury in the young athlete. The Journal of Bone and Joint Surgery Reviews, 7(9), e1. https://doi.org/10.2106/jbjs.Rvw.18.00197

20. Dwyer, J. T., Coates, P. M., & Smith, M. J. (2018). Dietary supplements: Regulatory challenges and research resources. Nutrients, 10(1). https://doi.org/10.3390/nu10010041

21. Faizan, U., & Rouster, A. S. (2024). Nutrition and hydration requirements in children and adults. In StatPearls. StatPearls Publishing. Copyright © 2024, StatPearls Publishing LLC.

22. Finnegan, E., Daly, E., Pearce, A. J., & Ryan, L. (2022). Nutritional interventions to support acute mTBI recovery. Frontiers in Nutrition, 9, 977728. https://doi.org/10.3389/fnut.2022.977728

23. Food and Nutrition Board, & Institute of Medicine. (2006). Dietary Reference Intakes: The essential guide to nutrient requirements. National Academies Press.

24. Gibbs, R. L., & Becker, T. B. (2025). General and sport-specific nutrition knowledge and behaviors of adolescent athletes. Journal of the Internation Society of Sports Nutrition, 22(1), 2477060. https://doi.org/10.1080/15502783.2025.2477060

25. Gibbs, R. L., Jr., & Becker, T. B. (2021). An evidence-based sports nutrition curriculum for youth. The Sport Journal, 24(6), 6-unpaginated. <Go to ISI>://CABI:20210342440

26. Giraldo-Vallejo, J. E., Cardona-Guzmán, M., Rodríguez-Alcivar, E. J., Kočí, J., Petro, J. L., Kreider, R. B., Cannataro, R., & Bonilla, D. A. (2023). Nutritional strategies in the rehabilitation of musculoskeletal injuries in athletes: A systematic integrative review. Nutrients, 15(4). https://doi.org/10.3390/nu15040819

27. Gropper, S. S., Smith, J. L., & Carr, T. P. (2018). Advanced nutrition and human metabolism. (7 ed.). Cengage Learning.

28. Hasan, S., Khatri, N., Rahman, Z. N., Menezes, A. A., Martini, J., Shehjar, F., Mujeeb, N., & Shah, Z. A. (2023). Neuroprotective potential of flavonoids in brain disorders. Brain Sciences, 13(9). https://doi.org/10.3390/brainsci13091258

29. Heikura, I. A., Uusitalo, A. L. T., Stellingwerff, T., Bergland, D., Mero, A. A., & Burke, L. M. (2018). Low energy availability is difficult to assess but outcomes have large impact on bone injury rates in elite distance athletes. International Journal of Sport Nutrition and Exercise Metabolism, 28(4), 403-411. https://doi.org/10.1123/ijsnem.2017-0313

30. Henriques, J. F., Serra, D., Dinis, T. C. P., & Almeida, L. M. (2020). The anti-neuroinflammatory role of anthocyanins and their metabolites for the prevention and treatment of brain disorders. International Journal of Molecular Sciences, 21(22). https://doi.org/10.3390/ijms21228653

31. Hirshkowitz, M., Whiton, K., Albert, S. M., Alessi, C., Bruni, O., DonCarlos, L., Hazen, N., Herman, J., Adams Hillard, P. J., Katz, E. S., Kheirandish-Gozal, L., Neubauer, D. N., O’Donnell, A. E., Ohayon, M., Peever, J., Rawding, R., Sachdeva, R. C., Setters, B., Vitiello, M. V., & Ware, J. C. (2015). National Sleep Foundation’s updated sleep duration recommendations: Final report. Sleep Health, 1(4), 233-243. https://doi.org/10.1016/j.sleh.2015.10.004

32. Hulland, S. C., Trakman, G. L., & Alcock, R. D. (2023). Adolescent athletes have better general than sports nutrition knowledge and lack awareness of supplement recommendations: a systematic literature review. British Journal of Nutrition, 1-15. https://doi.org/10.1017/s0007114523002799

33. Imbergamo, C. M., Patankar, A. G., & Milewski, M. D. (2021). Sleep optimization in the young athlete. Journal of the Pediatric Orthopaedic Society of North America, 3(3), 306. https://doi.org/https://doi.org/10.55275/JPOSNA-2021-306

34. Institute of Medicine of the National Academies. (2006). Dietary Reference Intakes.  The essential guide to nutrient requirements. The National Academies Press.

35. Iwasaki, M., Akiba, Y., & Kaunitz, J. D. (2019). Recent advances in vasoactive intestinal peptide physiology and pathophysiology: focus on the gastrointestinal system. F1000Research, 8. https://doi.org/10.12688/f1000research.18039.1

36. Karwowska, M., & Kononiuk, A. (2020). Nitrates/nitrites in food-risk for nitrosative stress and benefits. Antioxidants (Basel), 9(3). https://doi.org/10.3390/antiox9030241

37. Kenney, E. L., Long, M. W., Cradock, A. L., & Gortmaker, S. L. (2015). Prevalence of inadequate hydration among US children and disparities by gender and race/ethnicity: National Health and Nutrition Examination Survey, 2009-2012. American Journal of Public Health, 105(8), e113-118. https://doi.org/10.2105/ajph.2015.302572

38. Kerr, Z. Y., Chandran, A., Nedimyer, A. K., Arakkal, A., Pierpoint, L. A., & Zuckerman, S. L. (2019). Concussion Incidence and Trends in 20 High School Sports. Pediatrics, 144(5). https://doi.org/10.1542/peds.2019-2180

39. Koon, G., Atay, O., & Lapsia, S. (2017). Gastrointestinal considerations related to youth sports and the young athlete. Translational Pediatrics, 6(3), 129-136. https://doi.org/10.21037/tp.2017.03.10

40. Kozhuharov, V. R., Ivanov, K., & Ivanova, S. (2022). Dietary supplements as source of unintentional doping. BioMed Research International, 2022, 8387271. https://doi.org/10.1155/2022/8387271

41. Krabak, B. J., Roberts, W. O., Tenforde, A. S., Ackerman, K. E., Adami, P. E., Baggish, A. L., Barrack, M., Cianca, J., Davis, I., D’Hemecourt, P., Fredericson, M., Goldman, J. T., Harrast, M. A., Heiderscheit, B. C., Hollander, K., Kraus, E., Luke, A., Miller, E., Moyer, M.,…Wasfy, M. M. (2021). Youth running consensus statement: minimising risk of injury and illness in youth runners. British Journal of Sports Medicine, 55(6), 305-318. https://doi.org/10.1136/bjsports-2020-102518

42. Kreider, R. B., Kalman, D. S., Antonio, J., Ziegenfuss, T. N., Wildman, R., Collins, R., Candow, D. G., Kleiner, S. M., Almada, A. L., & Lopez, H. L. (2017). International Society of Sports Nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport, and medicine. Journal of the International Society of Sports Nutrition, 14, 18. https://doi.org/10.1186/s12970-017-0173-z

43. Krishna, G., Ying, Z., & Gomez-Pinilla, F. (2019). Blueberry supplementation mitigates altered brain plasticity and behavior after traumatic brain injury in fats. Molecular Nutrition & Food Research, 63(15), e1801055. https://doi.org/10.1002/mnfr.201801055

44. Logue, D. M., Madigan, S. M., Melin, A., Delahunt, E., Heinen, M., Donnell, S. M., & Corish, C. A. (2020). Low energy availability in athletes 2020: An updated narrative review of prevalence, risk, within-day energy balance, knowledge, and impact on sports performance. Nutrients, 12(3). https://doi.org/10.3390/nu12030835

45. Maier, J. A. M., Locatelli, L., Fedele, G., Cazzaniga, A., & Mazur, A. (2022). Magnesium and the brain: A focus on neuroinflammation and neurodegeneration. International Journal of Molecular Sciences, 24(1). https://doi.org/10.3390/ijms24010223

46. Manore, M. M., Patton-Lopez, M. M., Meng, Y., & Wong, S. S. (2017). Sport nutrition knowledge, behaviors and beliefs of high school soccer players. Nutrients, 9(4). https://doi.org/10.3390/nu9040350

47. Marshall, R. N., Smeuninx, B., Morgan, P. T., & Breen, L. (2020). Nutritional strategies to offset disuse-induced skeletal muscle atrophy and anabolic resistance in older adults: From whole-foods to isolated ingredients. Nutrients, 12(5). https://doi.org/10.3390/nu12051533

48. Maslowsky, J., & Ozer, E. J. (2014). Developmental trends in sleep duration in adolescence and young adulthood: evidence from a national United States sample. Journal of Adolescent Health, 54(6), 691-697. https://doi.org/10.1016/j.jadohealth.2013.10.201

49. Mason, L., Connolly, J., Devenney, L. E., Lacey, K., O’Donovan, J., & Doherty, R. (2023). Sleep, nutrition, and injury risk in adolescent athletes: A narrative review. Nutrients, 15(24). https://doi.org/10.3390/nu15245101

50. Melin, A. K., Areta, J. L., Heikura, I. A., Stellingwerff, T., Torstveit, M. K., & Hackney, A. C. (2024). Direct and indirect impact of low energy availability on sports performance. Scandinavian Journal of Medicine & Science in Sports, 34(1), e14327. https://doi.org/10.1111/sms.14327

51. Meng, X., Li, Y., Li, S., Zhou, Y., Gan, R. Y., Xu, D. P., & Li, H. B. (2017). Dietary sources and bioactivities of melatonin. Nutrients, 9(4). https://doi.org/10.3390/nu9040367

52. Milewski, M. D., Skaggs, D. L., Bishop, G. A., Pace, J. L., Ibrahim, D. A., Wren, T. A., & Barzdukas, A. (2014). Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. Journal of Pediatric Orthopaedics, 34(2), 129-133. https://doi.org/10.1097/bpo.0000000000000151

53. Nazem, T. G., & Ackerman, K. E. (2012). The female athlete triad. Sports Health, 4(4), 302-311. https://doi.org/10.1177/1941738112439685

54. Papadopoulou, S. K. (2020). Rehabilitation nutrition for injury recovery of athletes: The Role of macronutrient intake. Nutrients, 12(8). https://doi.org/10.3390/nu12082449

55. Pattnaik, H., Mir, M., Boike, S., Kashyap, R., Khan, S. A., & Surani, S. (2022). Nutritional elements in sleep. Cureus, 14(12), e32803. https://doi.org/10.7759/cureus.32803

56. Prus, D., Mijatovic, D., Hadzic, V., Ostojic, D., Versic, S., Zenic, N., Jezdimirovic, T., Drid, P., & Zaletel, P. (2022). (Low) energy availability and its association with injury occurrence in competitive dance: Cross-sectional analysis in female dancers. Medicina (Kaunas), 58(7). https://doi.org/10.3390/medicina58070853

57. QuickStats: Rates of injury from sports, recreation, and leisure activities among children and adolescents aged 1–17 years, by age group — National Health Interview Survey, United States, 2015–2017. (2019). Morbidity and Mortality Weekly Report, 68, 466.

58. Quintero, K. J., Resende, A. d. S., Leite, G. S. F., & Lancha Junior, A. H. (2018). An overview of nutritional strategies for recovery process in sports-related muscle injuries. Nutrire, 43(1), 27. https://doi.org/10.1186/s41110-018-0084-z

59. Raj, M., Creech, J., & Rogol, A. (2024). Female athlete triad. StatPearls Publishing. Retrieved February 3 from https://www.ncbi.nlm.nih.gov/books/NBK430787/

60. Rojano-Ortega, D., Peña Amaro, J., Berral-Aguilar, A. J., & Berral-de la Rosa, F. J. (2022). Effects of beetroot supplementation on recovery after exercise-induced muscle damage: A systematic review. Sports Health, 14(4), 556-565. https://doi.org/10.1177/19417381211036412

61. Ryan, J. L., Pracht, E. E., & Orban, B. L. (2019). Inpatient and emergency department costs from sports injuries among youth aged 5-18 years. BMJ Open Sport & Exercise Medicine, 5(1), e000491. https://doi.org/10.1136/bmjsem-2018-000491

62. Ryan, T., Nagle, S., Daly, E., Pearce, A. J., & Ryan, L. (2023). A potential role exists for nutritional interventions in the chronic phase of mild traumatic brain injury, concussion and sports-related concussion: A systematic review. Nutrients, 15(17). https://doi.org/10.3390/nu15173726

63. Sheehan, N., Summersby, R., Bleakley, C., Caulfield, B., Matthews, M., Klempel, N., & Holden, S. (2024). Adolescents’ experience with sports-related pain and injury: A systematic review of qualitative research. Physical Therapy in Sport, 68, 7-21. https://doi.org/https://doi.org/10.1016/j.ptsp.2024.05.003

64. Slavin, J. (2013). Fiber and prebiotics: mechanisms and health benefits. Nutrients, 5(4), 1417-1435. https://doi.org/10.3390/nu5041417

65. Smith-Ryan, A. E., Hirsch, K. R., Saylor, H. E., Gould, L. M., & Blue, M. N. M. (2020). Nutritional considerations and strategies to facilitate injury recovery and rehabilitation. Journal of Athletic Training, 55(9), 918-930. https://doi.org/10.4085/1062-6050-550-19

66. Smith, J. W., Holmes, M. E., & McAllister, M. J. (2015). Nutritional considerations for performance in young athletes. Journal of Sports Medicine (Hindawi Publ Corp), 2015, 734649. https://doi.org/10.1155/2015/734649

67. Standiford, L., O’Daniel, M., Hysell, M., & Trigger, C. (2021). A randomized cohort study of the efficacy of PO magnesium in the treatment of acute concussions in adolescents. The American Journal of Emergency Medicine, 44, 419-422. https://doi.org/https://doi.org/10.1016/j.ajem.2020.05.010

68. Sweeney, M. I., Kalt, W., MacKinnon, S. L., Ashby, J., & Gottschall-Pass, K. T. (2002). Feeding rats diets enriched in lowbush blueberries for six weeks decreases ischemia-induced brain damage. Nutritional Neuroscience, 5(6), 427-431. https://doi.org/10.1080/1028415021000055970

69. Thomas, D. T., Erdman, K. A., & Burke, L. M. (2016). Position of the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and athletic performance. Journal of the Academy of Nutrition and Dietetics, 116(3), 501-528. https://doi.org/10.1016/j.jand.2015.12.006

70. United States Olypmic & Paralymipic Committee Sport Nutrition Team. (2020a). Low energy availability. Retrieved December 17 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://assets.contentstack.io/v3/assets/blt9e58afd92a18a0fc/bltaa7a0653bc475a00/6470c42af0d737510db117f0/LEA_Fact_Sheet.pdf

71. United States Olypmic & Paralymipic Committee Sport Nutrition Team. (2020b). Nutrients for GI injury. Retrieved December 17 from https://assets.contentstack.io/v3/assets/blt9e58afd92a18a0fc/bltea94cc2ce765e25a/6470c42b20efde585ba537d8/NutrientsforGIInjury2020.pdf

72. United States Olypmic & Paralymipic Committee Sport Nutrition Team. (2020c). Nutrients for head injury recovery. Retrieved December 17 from https://assets.contentstack.io/v3/assets/blt9e58afd92a18a0fc/blta749d96eff2de64b/6470c42baf1a6843564609ee/NutrientsforHeadInjury2020.pdf

73. Wardenaar, F. C., Schott, K. D., Mohr, A. E., Ortega-Santos, C. P., & Connolly, J. E. (2023). An exploratory study investigating the prevalence of gastrointestinal symptoms in collegiate division I American football athletes. International Journal of Environ Research and Public Health, 20(15). https://doi.org/10.3390/ijerph20156453

74. Waterman, J. J., & Kapur, R. (2012). Upper gastrointestinal issues in athletes. Current Sports Medicine Reports, 11(2), 99-104. https://doi.org/10.1249/JSR.0b013e318249c311

75. Wiertsema, S. P., van Bergenhenegouwen, J., Garssen, J., & Knippels, L. M. J. (2021). The interplay between the gut microbiome and the immune system in the context of infectious diseases throughout life and the role of nutrition in optimizing treatment strategies. Nutrients, 13(3). https://doi.org/10.3390/nu13030886

76. Zamani, H., de Joode, M. E. J. R., Hossein, I. J., Henckens, N. F. T., Guggeis, M. A., Berends, J. E., de Kok, T. M. C. M., & van Breda, S. G. J. (2021). The benefits and risks of beetroot juice consumption: a systematic review. Critical Reviews in Food Science and Nutrition, 61(5), 788-804. https://doi.org/10.1080/10408398.2020.1746629

77. Zaslow, T., & Mitrovich, C. (2023). Chapter 16 – Gatrointestinal and abdominal issues. In B. J. Krabak & A. Brooks (Eds.), The Youth Athlete (pp. 159-172). Academic Press. https://doi.org/https://doi.org/10.1016/B978-0-323-99992-2.00090-6

2025-09-25T16:05:07-05:00February 18th, 2026|Research, Sport Education, Sport Training, Sports Medicine, Sports Nutrition|Comments Off on Supplemental lessons to the Peak Health and Performance curriculum: Nutritional considerations for injury, energy management, and gastrointestinal issues
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Navigating Anxiety and Aspiration: Mental Health and Intrinsic Motivation Among Black Former Student-Athletes at a Division I HBCU

Authors: Michael M. Bivins EdD

Mark Mitchell, DBA

Founder and President of Pride and Strive Inc., Mount Laurel, NJ, USA.

Editor’s Note: The address information for the Corresponding Author has been updated.


Corresponding Author:

Michael M. Bivins, EdD, MS,

One Academy Drive

Daphne, AL 36526

[email protected]

646-330-2157

Michael M. Bivins, EdD, is the founder and educator for Pride and Strive Inc. He is also an adjunct faculty member at the United States Sports University. His research interests include various health-related issues, including nutrition and the mental health of student-athletes.

Navigating Anxiety and Aspiration: Mental Health and Intrinsic Motivation Among Black Former Student-Athletes at a Division I HBCU

ABSTRACT

Purpose: An individual’s mental health can influence their decision-making and thought processes. For National Collegiate Athletic Association (NCAA) student-athletes, their mental health can impact their academic success. This study examined how mental health and intrinsic motivation influenced the academic success of seven Black former student-athletes at an HBCU (Historically Black Colleges and Universities). The mental health of student-athletes can play a significant role in their intrinsic motivation. Methods: Using qualitative analysis, the researcher interviewed former student-athletes who participated in semi-structured interviews analyzed using NVivo 12 of their experiences as a Black male and female student-athletes at an HBCU. The study consisted of seven Black student-athletes who played football or basketball for at least one year at an HBCU. The HBCU chosen represented NCAA Division Ⅰ in the Mid-Eastern Athletic Conference (MEAC). The researcher meticulously organized the qualitative study using the software NVivo 12, ensuring a comprehensive and reliable research process. Results: The data collected were rigorously analyzed to identify themes that emerged from the interviews. The data revealed four themes: 1) Anxiety, 2) Self-Motivation, 3) Social Life, and 4) Support from coaches and administration. Conclusions: The seven former student-athletes identified different factors contributing to their mental health and motivation for academic success. The overall environment at the HBCU, family support, and interactions with non-student athletes, coaches, faculty, and staff played a significant role in their psychological well-being and success. The researcher proposed recommendations for future research to explore the mental health issues of student-athletes at other institutions.

INTRODUCTION

Many student-athletes nationwide compete in the National Collegiate Athletic Association (NCAA). Their goal is to get an education while competing in their respective sport. According to the National Collegiate Athletic Association (n.d.), the NCAA is divided into Divisions Ⅰ, Ⅱ, and Ⅲ. NCAA Division Ⅰ has more than 300 colleges/universities and over 6,000 teams, with opportunities for over 170,000 student-athletes. 

Black student-athletes comprise most football and basketball players competing within NCAA Division Ⅰ. Ingraham (2020) noted that Black student-athletes make up sixty percent of basketball and football rosters while only representing eleven percent of the other sports rosters. Many studies examined Black student-athlete perspectives of competing within the NCAA Division Ⅰ athletics over the years. Numerous studies highlighted how Black student-athletes felt exploited by their colleges/universities. The exploitation of college athletes has been a topic of discussion for many years (Van Rheenen & Atwood, 2014). As exploitation can take different forms, the common theme for many student-athletes included athletic and economic factors. There is also a lack of educational emphasis from their college/university (Logan et al., 2017).

The college experience and motivation to succeed will vary from person to person, and everyone will have the goals they want to achieve. Many student-athletes must endure different obstacles that can strain their mental health. Some mental health problems include depression, anxiety, and dealing with different traumas. For black student-athletes, a supportive college environment can be essential to their athletic and academic success.

Over the past few years, mental health has been an essential topic of discussion among many people. Student-athletes are uniquely juggling their education and competing in their sport. Many student-athletes compete in the NCAA to get an excellent education at their respective institutions. The word student-athlete reminds everyone that students in the NCAA are at their college mainly for educational purposes. Student-athlete is a term that lawyers of the NCAA created in 1955 to avoid the notion that the players were employees (Posner & Schneider, 2021). This study examined the mental health and intrinsic motivation of seven black former student-athletes who competed in an HBCU (Historically Black Colleges and Universities) football and basketball program. The study examined the student-athletes intrinsic motivation and their influence by mental health factors, which included anxiety, stress, and social pressures.

Students have different levels of intrinsic motivation when dealing with the obstacles and challenges they may face during their transition into college (Daniels & Araposatathis, 2005). The mental health of student-athletes can play a significant role in their intrinsic motivation. This study looked at former student-athletes who provided an in-depth analysis of their experiences as Black male and female student-athletes at an HBCU. As many HBCUs compete within the NCAA Division Ⅰ athletics, it is common for top African American student-athletes to ultimately choose to attend larger PWIs (Predominantly White Institutions) (Hill, 2019). To date, very limited research has examined the mental health of Black former student-athletes who competed at an NCAA Division Ⅰ HBCU. As there are a small number of HBCU Division Ⅰ football and basketball programs, this study provided a research gap into the perspective of a small population compared to Black former student-athletes who competed at a PWI.

The Environment of Black Student-Athletes

According to Beamon (2014), African American student-athletes at PWIs face difficulties that include social and academic integration and various forms of racism.

One of the biggest stereotypes cited in the study was the perception that African American students at PWIs are only there for their athletic ability and not academics. The stereotype was toward both African American student-athletes and non-athlete African American college students. Tran et al. (2021) stated that student-athlete status might be an advantage for White student-athletes but a disadvantage for Black student-athletes when considering their peers’ perception of their academic success and intelligence.

In a study, Beamon (2014) noted that many African American student-athletes experienced racism beyond the classroom. Respondents revealed that sports did not necessarily bring different races and cultures together. Many respondents have felt a racial divide in the locker room. Experiencing racism can contribute to the mental health burden of Black individuals in the United States (Volpe et al., 2020). Cooper and Newton (2021) Mentioned that discriminatory incidents are not isolated to athletics but shared through academic and social spaces. Moreover, Museus et al. (2018) stated that college students are more contented and have a better sense of belonging when around people from the same cultural background.

Self -Determination Theory and Intrinsic Motivation

Self-determination theory (SDT) is a theory that explores human motivation and personality, where an individual can achieve self-determination through various factors (Ryan & Deci, 2000). The theory investigates an individual’s growth tendencies and inner psychological needs, which are the foundation of self-motivation. Within SDT, three essentials influence individual satisfaction. They include competence, relatedness, and autonomy (Ryan & Deci, 2000). However, it is essential to note that environmental factors can sometimes act as barriers, hindering self-motivation, social functioning, and overall personal well-being (Ryan & Deci, 2000).

Motivation consists of energy, direction, and persistence, which all contribute to the activation of an intention (Ryan & Deci, 2000). Furthermore, motivation has a high value due to the results that occur from it (Ryan & Deci, 2000). People are motivated by different factors with varied experiences and consequences (Ryan & Deci, 2000). There are different types of motivation that one may experience. Intrinsic motivation is an inherent form of motivation that leads to personal satisfaction (Ryan & Deci, 2000). Legault (2016) described intrinsic motivation as the engagement in activities or behaviors that are intrinsically satisfying. Intrinsic motivation is the highest level of self-determination (Holopainen et al., 2021). Intrinsic motivation is a natural inclination toward assimilation, mastery, and interest important to cognitive and social development (Ryan & Deci, 2000). People can be motivated by the value of an activity (Ryan & Deci, 2000). Another form of motivation Ryan and Deci (2000) noted is extrinsic motivation. Extrinsic motivation is the performance of an activity to achieve a separable outcome (Ryan & Deci, 2000). 

The Mental Health of the Black Student-Athlete

According to the NCAA, a recent study showed that mental health issues are still a significant concern among all NCAA student-athletes (Johnson, 2022). As Black students transition from high school into college, the accumulation of stress associated with the transition becomes a concern (Brittian et al., 2009). All student-athletes, generally, have been viewed as at risk for anxiety, depression, substance use, eating disorders, and performance-related stress (Kilcullen et al., 2022). African Americans tend to suffer from diseases related to mental illnesses, such as stress and anxiety, disproportionately (Reid & Smalls, 2004). According to Armstrong et al. (2015), only 20% of college students with mental health issues seek help from the provided services.  Student-athletes underutilize their health and counseling services more than non-student-athletes (Armstrong et al., 2015). The opposing views on seeking mental health help are prevalent in African American communities (Alvidrez et al., 2008).

Armstrong et al. (2015) also stated that the stigma of seeing a counselor is a weakness within the athletic subculture. The NCAA has recognized that their student-athletes mental health should become more emphasized (Henry, 2022). The NCAA has also acknowledged coaches’ role in helping student-athletes get the support and treatment they may need (Nocera, 2016).  There is a high probability that student-athletes on every college campus have some form of mental health issue, and Noncognitive characteristics of student-athletes have influenced academic performance (Comeaux & Harrison, 2011). 

Lindberg (2021) alluded to a crisis in the NCAA where there continues to be a significant percentage of student-athletes who ask for help managing stress and anxiety.  Furthermore, a survey conducted in 2015 found that 30% of student-athletes reported feeling overwhelmed (Lindberg, 2021). Coaches and parents of student-athletes usually emphasize performance over personal growth and character (Lindberg, 2021). 

Sense of belonging

Penner et al. (2021) noted that a sense of belonging, and a positive environment are essential to a student’s mental health and potential for academic achievement. In a study, Penner et al. (2021) stated that having a friendly and supportive faculty/staff contributed to a sense of belonging. A warm and friendly environment from other students on campus will also contribute to a sense of belonging. According to O’Keeffe (2013), a sense of belonging is also a contributing factor when considering the retention rates of all students. O’Keeffe (2013) noted that the institution must create an environment where students feel welcomed and accepted. The Need to Belong Theory states that belonging should be essential in all humans and cultures (Baumeister & Leary, 1995). Baumeister and Leary (1995) maintained that belongingness should entail an individual having a certain minimum quantity and quality of social contacts and interactions.  

According to Baumeister and Leary (1995), belongingness has two main features. The first feature is frequent contact and interactions with others. The second and equally important feature of belongingness is the feeling that a bond or relationship becomes marked by stability, emphasizing the importance of long-term connections in the Need to Belong theory. 

METHODS

Subjects and Instrumentation

For the study, the participants were Black male and female, former student-athletes who played football or basketball for at least one year at an HBCU. The HBCU selected represented NCAA Division Ⅰ in the Mid-Eastern Athletic Conference (MEAC). For research, a selection of seven participants represented students from different graduating years. The graduating years for the student-athletes ranged based on the year the participants entered college. The graduating years were essential to the study because they gave the researcher an idea of how the student-athletes viewed their HBCU over the years regarding their mental health and intrinsic motivation.

The instrument used was an interview guide. Conducting in-depth interviews was essential for this study because it helped understand the student-athlete’s experiences. 

The study employed semi-structured interviews, a method in which the researcher asked the participants questions related to two broad topics. The researcher chose the approach to foster a more natural and open conversation, respecting the individuality of each participant and enabling the researcher to understand the student-athlete’s experiences better.

  • RQ1: What influence did faculty and staff at the HBCU have on Black male and female student-athletes when examining their mental health and intrinsic motivation to succeed academically?
  • RQ2: How has the overall environment at the HBCU helped the student manage their mental health and intrinsic motivation for academic success?

Table 1 indicates a summary of demographic information of the participants.

Table 1:

 Demographic of Participants

CharacteristicNumber
Gender 
Female2
Male5
Sport 
Men’s Basketball2
Women’s Basketball2
Football3
Graduated 
Men’s Basketball1
Women’s Basketball2
Football3

Table 2 represents the sport and year the participants left the institution.

Table 2:

Year Student Left Institution

YearSport
2009Football
2010Football
2013Football
2016Men’s Basketball
2019Women’s Basketball
2020Women’s Basketball
2021Men’s Basketball

Table 3 represents the age of the participants at the time of the interview.

Table 3:

Age of Participants (at the time of interviews)

ParticipantAge
Football Athlete 135
Football Athlete 235
Football Athlete 331
Male Basketball Player One31
Female Basketball Player One25
Female Basketball Player Two24
Male Basketball Player Two23

Validity and Reliability

The researcher ensured the trustworthiness of the data collected and used peer debriefings from an expert in the mental health field and another experienced qualitative researcher to validate interpretations, increase objectivity, and minimize researcher bias. Peer debriefing helped in the formation of unbiased questions during the interviews. Furthermore, the researcher used reflexibility and approached the interviews with an open mind. Although not a former student-athlete, the researcher attended two HBCUs. The researcher needed to put any personal experiences of past interactions with HBCU student-athletes aside to ensure transparency and trustworthiness of the data collected.

NVivo 12 was chosen for qualitative research because it helped the researcher identify patterns in the participants’ responses. Further, NVivo helped the researcher identify any connections or relationships in the participants’ overall experiences. The themes that were developed were analyzed based on the patterns revealed by analyzing the software.

Procedures and Data Analysis

The researcher employed purposive sampling to select participants for the study. The selection of participants involved carefully judging who best fit the study’s criteria. Specifically, the researcher contacted eight (8) Black former student-athletes who had previously played football and basketball at the selected HBCU. Seven of the participants responded and agreed to take part in the research. 

The Institutional Review Board (IRB) approved the study of the participation of former student-athletes. Before the interviews, the researcher sent the participants an informed consent document to be signed and returned. The researcher also sent the participants a demographic questionnaire to be answered and returned. The researcher constructed a total of 14 open-ended questions for the interviews. The researcher asked follow-up questions that allowed the participants to elaborate honestly. With permission from participants, the researcher video-recorded the interviews and used Zoom recording software. The former student-athletes provided consent for recording. The average interview length was 20 minutes. 

Data were analyzed to identify themes that emerged from the interviews. During the interviews, the researcher took additional notes for reference. The interviewer transcribed the data using transcription software. NVivo 12 was used to organize and analyze the data. To ensure the accuracy of the data, the author checked all transcripts and video-recorded interviews. When analyzing, the researcher identified codes. The codes were then further analyzed to identify themes within the data.

RESULTS

After the researcher conducted and analyzed the interviews, five themes emerged.  The themes included the following:

  1. Anxiety (Research Questions One)
  2. Self-Motivation (Research Questions Two)
  3. Social Life (Research Question Two)
  4. Support from coaches and administration (Research Question One)

Table 4 indicates the themes that emerged and representative quotes of the participants interviewed.

Table 4:

Themes and Representative Quotes

Theme OverviewRepresentative Quotes
Theme 1: Anxiety
Codes for anxiety included: overwhelmed, balancing school and athletics, mental health services, and religion.“I actually had to go to the wide receiver coach and tell him that I had to remove myself from off of the team because I felt my grades were [suffering].”
“So, when you are a student athlete at the division one level, you are waking up at four o’clock in the morning working out. Then, you have to get study hall hours.”
“Having better [mental health] services was probably the biggest thing that I would change about my experience.”
“Pray. [I] Definitely pray.”
Theme 2: Self-Motivation
Codes for self-motivation included: Intrinsic motivation, and family support.“I’ve just learned to be mentally tough. And that was definitely instilled in me from a young age.”
“Oh yeah. So that was the easiest part for me. My family. I was just trying to be the first in my family to graduate college, which I have done.”
Theme 3: Social Life
Codes for social life included: non-student-athletes, HBCU culture, and other student-athletes.“Being around other people [non-student-athletes] … It’s real fun.”
“Everything was so positive … Everybody.
“I did hang out with the [other] athletes of course.”
Theme 4: Support from coaches and faculty members
Codes for the support from coaches and faculty members included: Scheduling, academic advisors, coaches, and support from professors.“No [scheduling conflict]. My own advisors pretty much set everything up for me.”
“There would be times when I would turn to one of the academic advisors, who was there [for support].
“I was fortunate enough to have a coach who … cared about what you were doing off the field.”
“I did rely on my assistant coach … She was amazing … I had really bad anxiety during that time.”

Theme and Codes

Note. The figure represents the four codes that relate to the theme.

All participants in the study mentioned experiencing some form of anxiety throughout their collegiate careers. Two of the seven participants used their religion, where they relied on prayers to get through some of their challenges. With the anxiety that the student-athletes experienced, the participants felt overwhelmed. All Participants mentioned it was often challenging to balance school and athletics. Female basketball player one was overwhelmed by the demands of her sport and not getting what she felt was the HBCU experience she always wanted. The theme of anxiety connects to research question one. It appeared that the administration, coaches, and faculty did not have a significant influence on the participants to seek mental health assistance, as five of the seven participants were not aware of mental health services offered.

Theme and Codes

Note. The figure represents the two codes that relate to the theme

The theme of self-motivation was associated with research question two. The overall environment did not hinder the participant’s goals for academic success, as six of the seven participants expressed the need to take advantage of their opportunity to get a college degree while doing what they loved in their sport. Football athlete three mentioned that his self-motivation came from different areas in his life. One thing that motivated him was feeling like he did not do well academically in high school. He wanted to prove that he could do better academically at the collegiate level. Four of the seven participants mentioned their families and used them as intrinsic motivation to succeed academically. Football athlete two and Football athlete three mentioned that they got their intrinsic motivation to succeed academically from seeing people within their family graduate with their college degrees. They wanted to continue with the success they already saw in their families. 

Theme and Codes

Note. The figure represents the three codes that relate to the theme

As there was a high demand for the participants to manage athletics and academics, most participants mentioned that having a social life was essential. Research question two was associated with the theme of social life. There were positive interactions with others on campus. Six of the seven participants in the study mentioned that they had friends who were non-student-athletes.  Male basketball player one and male basketball player two mentioned that they appreciated many non-student-athletes during college.

Female basketball player two mentioned that she had good relationships with other students in her major department as she believed that healthy relationships with others were important.  Football athlete three and male basketball player one also mentioned they had good relationships with student-athletes and non-student-athletes.

Theme and Codes

Note. The figure represents the four codes that relate to the theme

Support from coaches and faculty members was one of the most compelling themes related to research question one. Six of the seven participants appreciated the support they received from their coaches and faculty members. All participants mentioned that support was necessary for their mental health and overall success. The support came in different forms that included scheduling, mentorship, and mental well-being.

DISCUSSION

Research Question One: What influence did faculty and staff at the HBCU have on Black male and female student-athletes when examining their mental health and intrinsic motivation to succeed academically?

The study’s findings revealed that faculty and staff had an impact on their student-athletes. Consistent with prior research by Penner et al. (2021), the friendly and supportive faculty/staff contributed to a sense of belonging. There was tremendous encouragement from the participant’s coaches and professors to excel in their education. In addition to the support from coaches and professors, two participants also mentioned that academic advisors played a tremendous role in their academic development. The study was consistent with the self-determination theory. As Ryan and Deci (2000) cited, competence, relatedness/connectedness, and autonomy are three conditions of the Self-Determination Theory (SDT) that influence intrinsic motivation. The support of faculty and coaches indicated autonomy and competence. Autonomous supportive teachers enhance their students’ intrinsic motivation (Ryan & Deci, 2000).

All participants in the study mentioned that they experienced some form of anxiety and felt overwhelmed as a student-athlete. As the mental health of student-athletes is important, it is also vital to examine how they deal with their mental health issues. College faculty and administration should continue to take note of their role in minimizing the psychological distress of their students. Consistent with prior research conducted by Johnson (2022), mental health issues were a significant concern among the student-athletes.

It is important to note that two of the seven participants were female. There was a notable difference in the gender dynamics regarding mental health issues. In contrast to the male participants, the female participants heavily relied on their coaches for emotional support when they felt they missed their families. In addition, female basketball player one was the only participant who utilized the mental health services offered. The study revealed that the female participants were slightly more mindful of their psychological well-being.

At HBCUs, the significant presence of Black coaches and faculty members, in contrast to PWIs, has a profound cultural influence on their students. As Klopfenstein (2005) noted, culturally similar teachers can positively influence students of the same culture. The warmer relationship between coaches and their student-athletes at HBCUs, as reported by Murty et al. (2014), further underscores this cultural influence. Many participants expressed their gratitude for the support their coaches provided. 

Collectively, the student-athlete’s narratives support faculty and staff’s critical role in their academic development. Five of the seven participants heavily relied on their coach’s support and mentioned that their coaches played a significant role in their academic development. Academic advisors also played a critical role and helped the student-athletes get through challenging tasks. The positive feedback and interactions from coaches, faculty, academic advisors, and family members helped the former student-athletes achieve autonomy and competence. The participants believed they were in an environment that fostered their ability to achieve their academic and athletic goals. According to the SDT, a competent individual would feel like they can master a task and have the confidence to succeed and grow (Ryan & Deci, 2020). Ryan and Deci (2020) stated that there is a link between intrinsic motivation and the fulfillment of the needs for autonomy and competence. This study highlights the influence of staff and faculty at the HBCU in encouraging the student-athlete’s intrinsic motivation to succeed academically.

Research Question Two: How has the overall environment at the HBCU helped the student manage their mental health and intrinsic motivation for academic success?

The participants benefited from the social life outside of athletics, and there was interaction and support from non-student-athletes on campus. Most participants appreciated the HBCU culture; they felt it was an overall supportive environment. The study revealed consistent findings with prior research conducted by Museus et al. (2018), which found that college students are more contented and have a better sense of belonging when around people from the same cultural background.

The study revealed that positive interactions with teammates and other student-athletes from different sports on campus were critical for success. In the SDT, people have a high sense of relatedness when they experience connections with other people, enhancing their sense of belonging (Ryan & Deci, 2020). Communication and support of other student-athletes were effortless due to the commonalities that they shared. In addition to the positive interactions with other student-athletes, participants also felt connected with non-student-athletes.

The study indicated that student-athletes who have connections and gain support from non-student-athletes can have a positive impact. The positive interaction with non-student-athletes on campus also enhanced a sense of belonging. The sense of belonging enhanced the participant’s intrinsic motivation because the interactions with others did not add stress, anxiety, or other mental health issues. A high sense of belonging can increase a student’s motivation, academic engagement, and confidence (Kelly et al., 2024).

The participants demonstrated high self-motivation, as six of the seven participants had high levels of intrinsic motivation to succeed in academics, leading to their college degrees. The participants wanted a promising career after college. The theme of self-motivation emphasized the role of outside influences, such as family and friends, on student-athletes. The interviews did not reveal that the participants had a high athletic identity. When student-athletes perceive themselves as having high levels of athletic identity, there is a negative correlation between their academic motivation and grade point averages (GPA) (Bimper, 2014).

None of the participants mentioned that they experienced any form of racism on campus. Previous studies cited that Black student-athletes experience racism at PWIs.  Beamon (2014) stated that Black student-athletes felt negatively stereotyped at their PWI. Tran et al. (2021) stated that the perception of a student-athlete at PWIs is positive for White student-athletes and negative, with a disadvantage for Black student-athletes when considering their peers’ perception of their academic success and intelligence. The study participants did not feel negatively stereotyped as being academically inferior.

This study highlights HBCUs’ relevancy and cultural role to Black students, whether student-athletes or non-student-athletes. Shuler et al. (2022) noted that many Black students believe that HBCUs are culturally relevant and safe environments that are free from any racial hostility they perceive at PWIs. Furthermore, students who attend HBCUs are more likely to graduate and achieve advanced degrees (Shuler et al., 2022). As noted in the study, there is a heavy emphasis on academic achievement from coaches, faculty, and administration.

CONCLUSIONS

This study examined the mental health and intrinsic motivation of Black former student-athletes at one selected HBCU. The former student-athletes represented NCAA Division Ⅰ. Results indicated that family support and positive interactions with others on campus, including non-student-athletes, faculty, and coaches, can positively impact a student-athlete’s mental health. The research conducted highlighted the relevancy of the self-determination theory. When examining an individual’s potential for academic success, there is an emphasis on components of the theory (relatedness, autonomy, and competence) throughout the study. The NCAA must continue to encourage their institutions to accentuate the importance of managing the mental health of their student-athletes. Implementing policies that underline the importance of mental health services and resources can improve well-being. A limitation of this study is the selection of one HBCU. As the college experience can vary from person to person, researchers can expand this study to former NCAA Division Ⅰ student-athletes who attended other HBCUs. In addition, expanding to HBCU NCAA Division II and III would help get the perspective of student-athletes who compete at different levels. Another limitation was a focus on student-athletes who competed in football and basketball. Future research must consider student-athletes from various sports to build on this study’s findings. In addition, future research should explore the mental health and intrinsic motivation of Black former student-athletes who attended PWI compared to those who attended HBCUs. As there are different methodological approaches, a cross-sectional comparison with Black former student-athletes at PWIs and HBCUs would help understand the differences in the student’s environment, psychological health, and interactions with others.

APPLICATIONS IN SPORT

The NCAA can use this study to continue encouraging their student-athletes to use their schools’ mental health services. Additionally, this study can encourage the NCAA and other institutions to implement and update policies supporting mental health awareness. Administrators at HBCUs can use the information presented in this study to develop and implement policies geared toward their student-athletes. Moreover, this study can help faculty members and coaches better understand their role in helping student-athletes increase their psychological well-being and motivation to succeed academically.   

2025-08-11T08:11:47-05:00August 9th, 2025|General, Sports Health & Fitness, Sports Medicine, Sports Studies, Sports Studies and Sports Psychology|Comments Off on Navigating Anxiety and Aspiration: Mental Health and Intrinsic Motivation Among Black Former Student-Athletes at a Division I HBCU
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Efficacy of 12-Week Handgrip Strength Training Program Amongst Older Adults: A Pilot Study 

Author’s: Abbey Keller1, David Cason1, Shannon Hardy2, Madison Norris2, Angila Berni1, Michel Heijnen1, Alexander McDaniel1, Lindsey Schroeder1, Tiago Barriera3, Wayland Tseh1

1 School of Health and Applied Human Sciences, University of North Carolina Wilmington, Wilmington, North Carolina, United States of America

2 Carolina Bay at Autumn Hall, 630 Carolina Bay Drive., Wilmington, North Carolina, United States of America

3 School of Education, Syracuse University, Syracuse, New York, United States of America 

Corresponding Author: 

Lindsey H. Schroeder, Ed.D., LAT, ATC, CES

University of North Carolina Wilmington
School of Health & Applied Human Sciences

601 South College Road
Wilmington, NC 28403-5956
O: (910) 962-7188

F: (910) 962-7073

ABSTRACT 

Handgrip strength is indicative of overall health and longevity. The significance of a strong grip increases with age as it relates to lower mortality rates and improved functional capacity.

PURPOSE: To evaluate the effectiveness of a 12-week handgrip strength training program amongst older adults. METHODS: A total of 12 participants (mean age = 82.7 ± 4.8 years; height = 160.7 ± 7.4 cm; body mass = 64.2 ± 13.9 kg; 2 males; 10 females) completed the 12-week exercise intervention. The participants engaged in a twice-weekly, 45-minute suspension training regimen that incorporated a range of exercises targeting upper body strength and stability. Handgrip strength was assessed via a handgrip dynamometer at baseline and post-intervention. A paired samples t-test was employed to assess differences between pre-and post-intervention grip strength. A Bonferroni correction was applied to mitigate the risk of Type I error due to multiple comparisons, setting the adjusted alpha level at p = 0.025. Effect sizes were calculated using Cohen’s d to assess the practical significance of the findings. RESULTS: The analysis revealed a statistically significant improvement in right-handgrip strength, with values increasing from 21.5 ± 1.3 kg in Week 1 to 23.0 ± 1.4 kg in Week 12 (p = 0.006). No significant improvement was observed in left-handgrip strength (20.2 ± 1.2 kg to 21.1 ± 1.5 kg; p = 0.12). The right handgrip strength demonstrated a large effect (d = 0.99), whereas the left handgrip strength exhibited a moderate effect (d = 0.48). CONCLUSION: Findings from this study suggest that the 12-week suspension training and handgrip strength exercise regimen was both statistically and practically effective in increasing HGS in older adults. PRACTICAL APPLICATIONS: Allied healthcare professionals should educate older adults on the importance of HGS and incorporate targeted exercises into their regimens to mitigate age-related functional decline and promote better outcomes.

KEYWORDS: Suspension Training, Longevity, Handgrip Strength

INTRODUCTION 

By the year 2050, the global population of older adults is projected to reach 2.1 billion (10). As this demographic shift occurs, various risks associated with aging, including falls, cognitive decline, and impaired longevity and quality of life, become increasingly concerning (8, 14, 45). A crucial yet frequently underappreciated factor contributing to falls and other age-related risks is diminished handgrip strength (HGS), which impairs an individual’s capacity to stabilize themselves and prevent injuries (16, 19). Research suggests that HGS is representative of overall body strength (1). Handgrip strength is defined as the maximum amount of force the hand generates when gripping an object. Thresholds for HGS required to perform functional tasks in older adults are estimated at greater than 18.5 kg for females and 28.5 kg for males (2). Beyond serving as a measure of physical strength, HGS is also a strong predictor of longevity and overall quality of life, making it especially relevant in the context of aging (1). Comprehending the relationship between HGS and other fitness components is essential for devising effective strategies to preserve functional independence and enhance quality of life, particularly as the global population experiences unprecedented aging trends.

According to the Centers for Disease Control and Prevention (CDC), falls represent the leading cause of mortality among individuals aged 65 years and older. Annually, approximately 36 million older adults experience falls, with 32,000 cases resulting in fatal outcomes (4). Falls impact the quality of life by jeopardizing health, mobility, and independence. Although multiple factors influence fall risk, prioritizing interventions to improve HGS may offer a practical and impactful approach to reducing the incidence of falls among older adults (24).

In 2016, Szulc and colleagues examined 890 men aged 50 and older, assessing appendicular skeletal muscle mass (ASM), physical function, and HGS (42). Over a 5-year follow-up period, 813 participants aged 60 and above were monitored, of whom 144 experienced multiple falls. Findings from this research investigation revealed that those who sustained Grade 2 or Grade 3 vertebral fractures and multiple fractures had reduced HGS, decreased physical function, and an increased risk of multiple falls (42).

The number of global dementia cases is expected to almost triple from 57.4 million cases in 2019 to 152.8 million in 2050 (17). That said, aging significantly elevates the risk of cognitive decline, potentially leading to a loss of independence and other adverse outcomes. Although many factors are involved in preventing and treating cognitive decline and related illnesses, HGS may play a key role in determining who is at risk for these diseases. Physical impairments, such as diminished HGS, can interact with other factors to amplify the risk of age-related cognitive decline (7, 18). Consequently, investigating the relationship between HGS and cognitive function is essential for addressing the challenges of an aging global population.

In 2022, Orchard et al. evaluated both gait speed and HGS as predictors of cognitive decline and dementia (36). The participants were community-dwelling older adults who were cognitively intact at the onset of the study. Researchers assessed each participant’s 3-meter walk time and measured their HGS. A 4.7-year median follow-up was used to gather data on the prevalence of cognitive decline and dementia among participants. Slower walking gait and low HGS were independently related to an increased incident risk of dementia and cognitive decline. When these variables were combined, slow walking gait and low HGS were associated with a 79% increase in the risk of dementia development and a 43% increased risk of cognitive decline (36).

Precursory research has revealed that a culmination of exercise methods, including resistance training, Vitality Acupunch training program, multi-modal training, and suspension training (ST), can impact the HGS of older adults (2, 3, 10, 21, 23, 25, 26, 44). Among these, ST programs, such as total resistance exercise (TRX), stand out as accessible and adaptable methods. Due to the nature of ST, users possess the unique opportunity to train in several different facets of fitness at differing scalable resistances in a single bout of exercise (27). The suspension training system enables individuals to perform strength exercises adapted to their unique capabilities, offering progressive resistance to facilitate individualized strength development (15, 27).

In 2018, Campa, Silva, and Toselli conducted a study to determine the effects of a 12-week ST intervention on the phase angle and HGS of female older adults. Thirty older women were randomly assigned to either a control or training group. Participants in the control group continued their usual activities throughout the study, while those in the training group underwent a 12-week ST program. Both groups were assessed on various fitness parameters, including HGS. At the conclusion of the study, researchers found that ST promoted improvements in HGS in older women (3).

In 2022, Pierle and associates conducted a study to examine the efficacy of a 6-week ST program on a sample of 11 older individuals (37). The fitness parameters of interest were functional reach, overall balance, body fat, body mass, and HGS. While this study demonstrated improvements in functional reach and overall balance, body fat, body mass, and HGS showed no significant changes. These findings suggest that ST may be an effective exercise modality for enhancing certain aspects of fitness in older adults. However, further investigation is crucial to understand its impact on HGS better and determine whether ST can optimize strength outcomes in this population (37).

Against this backdrop, given the dearth of research examining the effects of ST protocols on HGS and the relationship between HGS and fall prevention, further investigation is imperative to elucidate the potential benefits of ST, especially amongst the older adult population. Therefore, the primary purpose of this study is to fill this critical gap by evaluating the efficacy of a 12-week ST and HGS exercise program in enhancing handgrip strength in this population. The apriori hypothesis posits that significant improvements in HGS will be observed between pre- and post-assessment measurements, underscoring the potential of ST and HGS as a targeted intervention to improve strength and reduce fall risk among older adults.

METHODS 

Participants

Prior to participating in this study, participants were screened using inclusionary and exclusionary criteria. The inclusion requirements included participants who currently exercise, are older than 55 years of age, and are independent of assistive walking devices (e.g., walker, rollator, wheelchair, etc.). The exclusionary criteria included participants not having a medical release form on record, being overwhelmed by the exercise routine, specifically, mild increases in heart rate and blood pressure during exercise, or possessing a pacemaker or other internally implanted device. All participants, therefore, were required to have a medical release to participate. This study was approved by the university’s institutional review board and adhered to the practice of ethical research standards.

All participants were recruited from a local retirement community and were required to report to the Wellness Center onsite for 24 sessions over 12 weeks. Flyers were posted, and those interested were instructed to sign up for an appointment with the principal investigator (PI) to complete the protocol requirements. Participants were encouraged to contact the PI or co-PI by phone or email if any question(s) arose or if any of the requirements remained unclear.

Upon arrival for the pre-assessment session, participants read/signed/dated an informed consent form approved by the University’s Institutional Review Board (IRB) for human subject use (IRB#: H24-0565). Ten females and 2 males (Age = 82.7 ± 4.8 years; Height = 160.7 ± 7.4 cm; Body Mass = 64.2 ± 13.9 kg), completed the 12-week exercise intervention.

Protocol

Once the informed consent was obtained, pre-assessment data was collected. All participants were instructed to remove footwear, socks, and stockings before stepping onto the scale. Height (cm) and body mass (kg) were assessed via Seca 217 Mobile Stadiometer (Model Number 2171821009, USA). The participant’s height and body mass results were displayed and recorded via a data collection sheet. Grip strength was assessed via the Smedley Creative Health Products III Analog Grip Strength Dynamometer (T.K.K. 5001, Japan). Participants were instructed to maintain the standard bipedal position during the entire test with the arm in complete extension and to avoid touching any part of the body with the handgrip dynamometer except the hand being measured. Participants comfortably grasped the handgrip dynamometer and were encouraged to exert maximal grip.

Three trials, with brief pauses, were allowed for each hand alternately. The sum of the highest left and right values was recorded on the data collection sheet. The PI was the lead exercise instructor of the 12-week exercise intervention. The PI took attendance, organized, and provided corrective feedback/instructions during each exercise session. A team of fitness instructors at the retirement community and a research assistant also led these classes by providing feedback to participants and keeping each session organized. The exercise intervention required participants to attend two sessions per week for 12 weeks, with each class being 45 minutes. Attendance was recorded at the start of each class to keep track of the adherence rate. Every session consisted of seven strength training exercises in a circuit style (Table 1), followed by a grip strength series consisting of four exercises (Table 2).

Strength training exercises were advanced every 4 weeks, specifically, progressing from 30-second intervals (first micro-cycle) to 35 seconds (second micro-cycle) to 40 seconds (final micro-cycle). The Farmer’s Carry exercise specifically intensified each micro-cycle, starting with holding one dumbbell each set, then holding one dumbbell each set vertically upright by the head of the weight, and finally holding the head of a dumbbell in each hand. The grip strength series progressed throughout the 12-week intervention, starting with one set of each exercise for 15 seconds per hand in the first 4 weeks and followed by 8 weeks of performing each exercise for two sets of 15 seconds. Each session started with a 5-minute warm-up, followed by 35 minutes of exercise, and concluded with a 5-minute cooldown. The 12-week exercise training intervention took place as a group fitness class in the fitness center of a local retirement community, giving participants the advantage of working with partners for each exercise, increasing accountability and motivation. The TRX suspension training (ST) allowed users to exercise in a customizable and scalable capacity that fits their personal specifications, comfort, and intensity levels (27). Additionally, the PI used a timed-circuit style class versus measuring each exercise based on repetition, allowing participants to perform at their own intensified pace.

Statistical Analysis

A paired samples t-test was employed to assess differences between pre-and post-intervention grip strength. To mitigate the risk of Type I error due to multiple comparisons, a Bonferroni correction was applied, setting the adjusted alpha level at p = 0.025. Effect sizes were calculated using Cohen’s d to assess the practical significance of the findings. 

RESULTS 

The primary objective of this study was to evaluate the efficacy of a 12-week exercise intervention on handgrip strength (HGS) in a population of community-dwelling older adults. Sixteen participants were initially recruited; however, four withdrew during the study, resulting in a final sample size of 12 participants (Age = 82.7 ± 4.8 years; Height = 160.7 ± 7.4 cm; Body Mass = 64.2 ± 13.9 kg; 2 males and ten females). Attendance was monitored at each session, yielding an average adherence rate of 83%. The adherence rate remained consistent throughout this study.

A paired-sample t-test was conducted to assess differences between pre- and post-intervention measurements. A Bonferroni correction was applied to mitigate the risk of Type I errors due to multiple comparisons, resulting in an adjusted alpha level of p = 0.025. Effect sizes were quantified using Cohen’s d, with thresholds of 0.2, 0.5, and >0.8 representing small, medium, and large effects, respectively.

The analysis revealed a statistically significant improvement in right-hand grip strength, which increased from 21.5 ± 1.3 kg at baseline (Week 1) to 23.0 ± 1.4 kg post-intervention (Week 12, p = 0.006). In contrast, no statistical improvement was observed for left-hand grip strength (20.2 ± 1.2 kg to 21.1 ± 1.5 kg, p = 0.12). The effect size for right-hand grip strength was large (d = 0.99), whereas the left-hand grip strength demonstrated a moderate effect (d = 0.48). Detailed results are presented in Table 3.

DISCUSSION 

Limited research exists with respect to investigating sustained strength training (ST) programs and handgrip strength (HGS) in older adults (12, 23). Therefore, the primary purpose of this study was to determine the efficacy of a 12-week ST and HGS exercise program in a community-dwelling older adult population. The researchers hypothesized a statistically significant improvement in HGS between pre- and post-assessment data. At the conclusion of the 12-week ST and HGS exercise program, right-HGS improved significantly and demonstrated a large effect size, while the left hand showed a moderate but non-significant change. These findings suggest that a 12-week suspension training exercise program may enhance grip strength and potentially improve functional independence and reduce fall risk in older adults. However, additional research is needed to fully understand these effects and any differences between dominant and non-dominant hands.

 In 2018, a research study was conducted by Campa and colleagues in which the participants were divided into two groups: 1) 12-week ST exercise group and 2) control group that maintained their usual daily activity (3). Both groups of participants underwent pre-and post-tests, evaluating several fitness components, including HGS. Findings from the current research study and the study by Campa et al. (3) revealed both shared and contrasting results in how structured exercise interventions affect HGS in older adults. More precisely, both studies reported statistically significant HGS improvements following their 12-week interventions. The current research study observed an increase in right-hand grip strength from 21.5 ± 1.3 kg to 23.0 ± 1.4 kg, equating to an approximate 7.0% improvement. Similarly, Campa et al. (3) reported an increase in dominant-hand HGS from 38.2 ± 9.7 kg to 40.1 ± 9.0 kg, reflecting a significant 4.97% improvement. Both findings confirm the efficacy of a 12-week exercise program in promoting upper-body strength among older adults. Notably, both studies targeted older adults, with the current study involving a mixed-gender cohort (mean age 82.7 years) and Campa et al. (3) focusing on men with a mean age of 67.4 years. Despite this approximate 15-year age difference, the consistency in outcomes underscores the adaptability of exercise interventions across different subsets of older adults. Both research studies spanned 12 weeks, suggesting that this time frame is sufficient to elicit measurable improvements in muscular strength. Given these similarities, improvements in HGS in both studies align with broader health and functional benefits. Because HGS is a well-established predictor of overall physical health (29, 35), these findings highlight the role of resistance-based interventions in enhancing the quality of life and functional independence among older adults.

While both studies displayed shared findings, it was noted that the baseline mean HGS of the current study was strikingly lower (21.5 ± 1.3 kg) compared to Campa et al.’s (3) sample group (38.2 ± 9.7 kg). This discrepancy may be due to the age difference of about 15 years, which more than likely contributed to variations in baseline physical fitness and adaptive capacity. Older adults often experience diminished neuromuscular responsiveness and muscle plasticity (7, 32).

To summarize, the current research study and Campa et al.’s (3) study demonstrate significant improvements in HGS following 12-week exercise programs, reinforcing the utility of structured ST in mitigating age-related strength decline. Both studies provide compelling evidence that targeted interventions can yield functional strength gains in older populations regardless of modality. However, the differences in participant demographics highlight the influence of baseline fitness levels and age on HGS outcomes.

The results from a study by Gaedtke and Morat (16) also revealed results like those of the current study. Eleven older adults (Mean Age = 66.0 ± 4.0 yrs) participated in a 12-week TRX-OldAge training program, composed of seven exercises progressing through multiple stages of difficulty. The intervention method utilized TRX equipment, shared by Gaedtke and Morat (16) and the current study. Both studies also had similar sample sizes and durations, spanning 12 weeks. The results displayed within Gaedtke and Morat’s (16) research study share thematic similarities with the current research in demonstrating improvements in HGS. Both studies emphasize the potential of targeted programs to enhance functional strength, which is critical for maintaining independence and reducing the risk of falls in aging populations. Specifically, the current research reported a 7.0% increase in right-hand grip strength, showcasing the tangible benefits of a 12-week intervention. Similarly, participants in Gaedtke and Morat’s (16) study subjectively reported strength gains as the most notable improvement following the TRX-OldAge program. However, Gaedtke and Morat (16) did not provide quantifiable pre- and post-assessment metrics for HGS, which limits direct comparisons. While participant feedback highlights strength improvements, the lack of quantifiable data undermines the ability to assess the efficacy of the intervention, specifically on grip strength. This limitation in Gaedtke and Morat’s (16) study underscores the importance of incorporating quantifiable assessments in future investigations to validate self-reported outcomes and to draw more substantial comparisons with similar studies. Regardless, given the vast similarities between the two research studies, it is evident that a TRX-related exercise regime conducted for 12 weeks does enhance muscular strength in older individuals.

In a study conducted by Skelton et al. (41), a 12-week progressive ST intervention was implemented to assess its effects on the strength, power, and functionality of women aged 75 and older (41). The intervention included three exercise sessions per week, with two sessions conducted at home and one in a group setting. The additional day of exercise, as well as the inclusion of home exercise sessions, differs from the current study, which took place twice a week in a group fitness class setting. While the exercises did not mimic the functional tests entirely, each session was tailored to work the specific muscles relevant for functional tasks. Exercises were performed in three sets of four to eight repetitions, using rice bags and elastic bands for resistance. An assortment of pre- and post-assessments were conducted, including a HGS test, resembling the current study.

Despite these methodological differences, Skelton and colleagues (41) demonstrated increases in HGS, which aligns with the improvements observed in the current research study. In Skelton et al.’s (41) 12-week progressive resistance training program, participants experienced a significant 4% increase in HGS, from a pre-training mean of 21.6 ± 3.4 kg to a post-training mean of 22.3 ± 3.9 kg. This outcome parallels findings from the current research study, whereby a significant 7% improvement in HGS was observed. This supports the notion that 12 weeks of functional resistance training may improve HGS amongst a sample of older individuals.

A potential explanation for the greater improvement in HGS observed in the current study may be the focused, grip-specific training regimen utilized. Skelton et al.’s (41) training program, while progressive and resistance-based, did not include exercises that mimicked or directly engaged the musculature required for grip strength improvement. Instead, the program targeted broader functional movements, such as knee extensors, elbow flexors, and other large muscle groups. This specificity likely contributed to the larger improvement in grip-related performance observed in the current study.

Because the current study partially mimicked and addressed some of the limitations of Pierle and colleagues (37), detailed comparative results will be described. Pierle et al. (37) evaluated the efficacy of a 6-week ST intervention on multiple fitness components of older adults (37). This intervention consisted of 1-2 sets of 8 ST exercises performed twice a week. At the conclusion of this study, participants showed improvements in several fitness and functional areas. In contrast to the current study, Pierle et al. (37) did not observe improvements in HGS.

In the current study, participants demonstrated a statistically significant improvement in right-HGS following a 12-week intervention. Pre-assessment HGS for the right hand was 21.5 ± 1.3 kg, which increased to 23.0 ± 1.4 kg, reflecting a 7.0% improvement and a large effect size (d = 0.99). Conversely, left-hand HGS exhibited a smaller, non-significant increase from 20.2 ± 1.2 kg to 21.1 ± 1.5 kg (4.5% improvement, d = 0.48). Comparatively, Pierle et al. (37) observed no statistically significant changes in HGS, with pre-assessment values averaging 22.4 ± 1.9 kg and post-assessment values averaging 22.8 ± 1.8 kg. The effect size (d = 0.03) was minimal, indicating negligible gains in grip strength.

The differences in duration and intervention may explain this disparity in findings. For instance, the intervention in Pierle et al.’s (37) study lasted for 6 weeks, with two sessions per week, totaling 12 training sessions. This short duration may have limited the time available for participants to experience significant neuromuscular adaptations, such as improved motor unit recruitment and muscle hypertrophy, which are crucial for strength gains (6, 33). In contrast, the current study required participants to exercise for 12 weeks, providing twice the intervention time, therefore allowing for a more progressive overload and adaptation. The longer program likely facilitated more robust changes in muscle strength, particularly in the dominant hand. Previous research documents that strength improvements, particularly in older adults, rely on consistent and prolonged exposure to resistance-based stimuli to elicit meaningful neuromuscular adaptations (9, 20).

Another potential reason for the difference in findings is the modality and specificity of exercises. Pierle and colleagues’ study (37) focused on general ST, which emphasized functional movements, overall balance, core stability, and flexibility but did not prioritize grip-intensive exercises. In contrast, the current study employed targeted resistance and isometric exercises specifically designed to enhance HGS, ensuring a more direct focus on grip-related adaptations. Previous research has shown that exercise modality plays a critical role in the specificity of adaptations (15, 21). The lack of direct HGS training in Pierle et al.’s (37) protocol likely limited the magnitude of HGS improvements compared to the current research study.

The current study displayed a statistically significant improvement in right-HGS. While no statistically significant improvement was observed in left-HGS. While said findings were unanticipated, previous research investigations have displayed similar asymmetrical findings (22, 30, 43). In 2008, Thomas & Sahlberg recruited 41 college-aged males and females to complete an 8-week resistance training protocol with the aim of enhancing HGS. Data revealed by Thomas and Sahlberg (2008) align closely with the current investigation in demonstrating significant improvements in right-hand HGS, while no significant changes were observed in the left-hand HGS. In Thomas and Sahlberg’s (43) study, participants in the training group exhibited a statistically significant increase in right-hand HGS (32.9 ± 8.6 kg to 35.5 ± 7.6 kg) over an 8-week general resistance training intervention. However, the left-hand HGS showed no significant changes (30.7 ± 8.4 kg and 30.2 ± 6.0 kg). Similarly, the current research reported a statistically significant improvement in right-hand HGS (21.5 ± 1.3 kg to 23.0 ± 1.4 kg) but observed no significant change in left-hand HGS, which increased only marginally from 20.2 ± 1.2 kg to 21.1 ± 1.5 kg.

The consistency between these studies highlights the tendency for dominant-hand HGS to exhibit greater responsiveness to resistance training interventions. Both studies emphasize the role of hand dominance in determining training outcomes, with dominant hands showing significant strength gains due to frequent daily use and greater neuromuscular efficiency (5, 39). Conversely, the non-dominant hand may require more targeted stimuli to achieve comparable improvements, as evidenced by the lack of significant HGS gains in the left hand in both studies (13, 40). These findings emphasize the importance of tailoring training programs to address asymmetries and maximize bilateral strength development.

In 2019, Labott and colleagues conducted a comprehensive meta-analytical review to evaluate the effects of various exercise interventions on HGS in older adults. The review analyzed 24 research articles involving 3,018 participants with a mean age of 73.3 years (22), focusing on interventions ranging from resistance training to multimodal programs. While the findings revealed small but statistically significant improvements in HGS overall, the results emphasized a common trend across studies to the extent that greater responsiveness in right-hand HGS compared to the left-hand HGS. These authors concluded that task-specific and multimodal training interventions often yielded measurable gains in dominant hand strength, as this hand benefits from more frequent use and neuromuscular efficiency in daily activities. In contrast, left-hand HGS frequently displayed minimal or no significant change, reflecting the need for targeted stimuli to elicit comparable adaptations in the non-dominant hand. The review highlights this asymmetry as a recurring observation in HGS research, reinforcing the importance of tailored interventions to address disparities between dominant and non-dominant hand strength (5,22).

Although no statistically significant improvement was observed in left-hand HGS among participants in the current study, the practical implications of the findings should not be overlooked. A mean increase of 1.1 kg (4%) represents a meaningful real-world difference, particularly within aging populations. For older adults, even modest improvements in HGS can translate into enhanced functional capacity, better mobility, fall mitigation, greater independence in activities of daily living, and improved overall quality of life (11, 22, 28, 31, 38, 46). Moreover, from an applied perspective, a 4% increase in left-hand HGS may provide critical support in scenarios requiring quick reflexive actions, such as maintaining balance or catching oneself during a fall (28, 34). This seemingly minor improvement could make a significant difference in preventing injury and maintaining mobility, highlighting the value of targeted interventions to enhance HGS, even in cases where statistical significance is not achieved.

There were several limitations to this study that may have impacted the results. The small sample size (n = 12) and the low male participation in this study may have stifled the results from reaching their full expression. Future studies would benefit from a larger and more gender-balanced sample to enhance the generalizability of findings. Additionally, an increased sample size would allow for a control group to be utilized, bolstering the findings of future studies. Adherence to the 12-week intervention proved difficult as it slowly declined by 17% throughout the study, as many participants had busy schedules and prior commitments that interfered with consistent session attendance. Future studies may consider methods to improve adherence, such as scheduling flexibility or at-home modifications. Longer intervention durations may yield more robust findings, as 12 weeks might not have allowed the intervention to reach its full potential. Confounding variables, such as diet, sleep, and baseline activity levels, were not accounted for and may have influenced the results. Tracking these variables in future studies could provide additional insights into their potential impact.

As individuals age, their priorities often shift toward improving quality of life, extending longevity, and maintaining functional independence. Because HGS directly impacts these aspects of healthy aging, its maintenance, or better yet, improvement, should remain a priority in interventions targeting older adults. The intention of this study was to discover the efficacy of a 12-week ST exercise intervention on the HGS of older adults and underscore its importance for healthy aging. The current study revealed a statistically significant improvement in right-HGS, whereas no significant improvement was observed in left-HGS. Future research should evaluate asymmetrical HGS, as this was not an anticipated finding. Additionally, further research should investigate ST in older adult populations, addressing the limited existing evidence on its efficacy in this demographic.

CONCLUSION 

Findings from this study suggest that the 12-week ST and HGS exercise regime was statistically and practically effective in increasing overall HGS in older adults. These findings may serve as valuable guidance for fitness instructors, physical therapists, and other allied healthcare professionals working with older adults. Integrating ST exercises and HGS-specific exercises results in improved HGS, an essential component of maintaining functional independence as individuals age. Utilizing the TRX system for this intervention provided unique advantages, as the exercises were simple to perform and customizable to each participant.

PRACTICAL APPLICATIONS

Implementing an exercise program focusing on HGS has broader implications, as HGS correlates with improved quality of life, longevity, and reduced risk of falls. Allied healthcare professionals working with older adult populations should educate their patients on the importance of HGS and adopt intentional HGS-focused exercises into their regimens. In doing so, they can help mitigate age-related functional decline and promote better outcomes for aging individuals.

ACKNOWLEDGMENTS

The author would like to personally thank the health and wellness team at Carolina Bay at Autumn Hall: Shannon Hardy and Madison Norris.

The author would also like to thank the Center for the Support of Undergraduate Research and Fellowships for their generous contributions.

REFERENCES 

  1. Attia, P. (2022, July 30). Avoiding Injury Part II: Grip Strength. Peter Attia MD. https://peterattiamd.com/avoiding-injury-part-ii-grip-strength/
  2. Bohannon, R.W. (2019). Grip strength: an indispensable biomarker for older adults. Clinical Interventions in Aging, 14, 1681–1691. https://doi.org/10.2147/CIA.S194543
  3. Campa, F., Silva, A., & Toselli, S. (2018). Changes in phase angle and handgrip strength induced by suspension training in older women. International Journal of Sports Medicine, 39(06), 442–449. https://doi.org/10.1055/a-0574-3166
  4. Centers for Disease Control and Prevention. (2022, June 9). Keep on your feet-preventing older adult falls. Centers for Disease Control and Prevention. https://www.cdc.gov/falls/about/?CDC_AAref_Val=https://www.cdc.gov/injury/features/older-adult-falls/index  
  5. Chapman, J. A., & Henneberg, M. (1999). Switching the handedness of adults: Results of 10 weeks training of the non-dominant hand. Perspectives in Human Biology, 4(1), 211–217. https://www.researchgate.net/publication/233726410
  6. Christie, A., & Kamen, G. (2010). Short-term training adaptations in maximal motor unit firing rates and afterhyperpolarization duration. Muscle & Nerve, 41(5), 651–660. https://doi.org/10.1002/mus.21539
  7. Clark, D.J., & Fielding, R.A. (2012). Neuromuscular contributions to age-related weakness. Journals of Gerontology: Series A, 67(1), 41–47. https://doi.org/10.1093/gerona/glr041
  8. Clark, S., Parisi, J., Kuo, J., & Carlson, M. C. (2016). Physical Activity Is Associated With Reduced Risk of Executive Function Impairment in Older Women. Journal of aging and health, 28(4), 726–739. https://doi.org/10.1177/0898264315609908
  9. Conlon, J.A., Newton, R.U., Tufano, J.J., Peñailillo, L.E., & Banyard, H.G. (2017). The efficacy of periodised resistance training on neuromuscular adaptation in older adults. European Journal of Applied Physiology, 117(1), 137–149. https://doi.org/10.1007/s00421-017-3605-1
  10. Cunningham, C., O’ Sullivan, R., Caserotti, P., & Tully, M.A. (2020). Consequences of physical inactivity in older adults: a systematic review of reviews and meta-analyses. Scandinavian Journal of Medicine & Science in Sports, 30(5), 816–827. https://doi.org/10.1111/sms.13616
  11. Damush, T.M., & Damush, J.G. Jr. (1999). The effects of strength training on strength and health-related quality of life in older adult women. The Gerontologist, 39(6), 705–710. https://doi.org/10.1093/geront/39.6.705
  12. Domingues, L.B., Schneider, V.M., & Abreu, R.F. (2024). Effects of a 4-week detraining period after 12 weeks of combined training using different weekly frequencies on health-related physical fitness in older adults. International Journal of Environmental Research and Public Health, 21(11), 1433. https://doi.org/10.3390/ijerph21111433
  13. Dunn, A.M. (2017). Non-dominant arm training improves functional performance and modifies spontaneous arm selection. Penn State University Libraries Theses and Dissertations. Retrieved from https://etda.libraries.psu.edu/catalog/13597amd460
  14. Fritz, N. E., McCarthy, C. J., & Adamo, D. E. (2017). Handgrip strength as a means of monitoring progression of cognitive decline – A scoping review. Ageing research reviews, 35, 112–123. https://doi.org/10.1016/j.arr.2017.01.004
  15. Fyfe, J.J., & Loenneke, J.P. (2018). Interpreting adaptation to concurrent compared with single-mode exercise training: Some methodological considerations. Sports Medicine, 48(2), 289–297. https://doi.org/10.1007/s40279-017-0812-1
  16. Gaedtke, A. & Morat, T. (2015). TRX suspension training: a new functional training approach for older adults – development, training control and feasibility.” International Journal of Exercise Science, 8(3), 224–233.
  17. GBD 2019 Dementia Forecasting Collaborators (2022). Estimation of the global prevalence of dementia in 2019 and forecasted prevalence in 2050: an analysis for the Global Burden of Disease Study 2019. The Lancet. Public health, 7(2), e105–e125. https://doi.org/10.1016/S2468-2667(21)00249-8
  18. Gudlaugsson, J., Gudnason, V., Aspelund, T., Siggerirsdottir, K., Olafsdottir, A.S., Jonsson, P.V., Arngrimsson, S.A., Harris, T.B., & Johannnsson, E. (2012). Effects of a 6-month multimodal training intervention on retention of functional fitness in older adults: a randomized-controlled cross-over design. International Journal of Behavioral Nutrition and Physical Activity, 9(107). https://doi.org/10.1186/1479-5868-9-107
  19. Haider, S., Luger, E., Kapan, A., Titze, S., Lackinger, C., Schindler, K.E., & Dorner, T.E. (2016). Associations between daily physical activity, handgrip strength, muscle mass, physical performance and quality of life in prefrail and frail community-dwelling older adults. Quality of Life Research, 25(12). https://doi.org/10.1007/s11136-016-1349-8
  20. Häkkinen, K., Alen, M., Kallinen, M., Newton, R.U., & Kraemer, W.J. (2000). Neuromuscular adaptation during prolonged strength training, detraining, and re-strength-training in middle-aged and elderly people. European Journal of Applied Physiology, 83(1), 51–62. https://doi.org/10.1007/s004210000248
  21. Isner-Horobeti, M.E., Dufour, S.P., Vautravers, P., & Geny, B. (2013). Eccentric exercise training: Modalities, applications, and perspectives. Sports Medicine, 43(6), 483–512. https://doi.org/10.1007/s40279-013-0052-y
  22. Labott, B.K., Bucht, H., Morat, M., Morat, T., & Donath, L. (2019). Effects of exercise training on handgrip strength in older adults: A meta-analytical review. Gerontology, 65(6), 686–696. https://doi.org/10.1159/000501203
  23. Leitão, L., Campos, Y., Louro, H., & Figueira, A.C.C., Figueiredo, T., Pereira, A., Conceicao, A., Marinho, D.A., & Neiva, H.P. (2024). Detraining and retraining effects from a multicomponent training program on the functional capacity and health profile of physically active prehypertensive older adults. Healthcare, 12(2), 271. https://doi.org/10.3390/healthcare12020271
  24. Liu, H., Hou, Y., Li, H., & Lin, J. (2022). Influencing factors of weak grip strength and fall: A study based on the China Health and Retirement Longitudinal Study (CHARLS). BMC Public Health, 22(1), 2337. https://doi.org/10.1186/s12889-022-14753-x
  25. López-Bueno, R., Andersen, L. L., Koyanagi, A., Núñez-Cortés, R., Calatayud, J., Casaña, J., & Del Pozo Cruz, B. (2022). Thresholds of handgrip strength for all-cause, cancer, and cardiovascular mortality: A systematic review with dose-response meta-analysis. Aging Research Reviews, 82, 101778. https://doi.org/10.1016/j.arr.2022.101778
  26. Mayer, F., Scharhag-Rosenberger, F., Carlsohn, A., Cassel, M., Muller, S., & Scharhag, J. (2011) The intensity and effects of strength training in the elderly. Deutsches Ärzteblatt International, 108(21), 359-364. https://doi.org/10.3238/arztebl.2011.0359
  27. McDaniel, A. T., Heijnen, M. J. H., Kawczynski, B., Haugen, K. H., Caldwell, S., Campe, M. M., Conley, E. C., & Tseh, W. (2023). Efficacy of Army Combat Fitness Test 12-Week Virtual Exercise Program. Military medicine, 188(7-8), e2035–e2040. https://doi.org/10.1093/milmed/usac364
  28. McGrath, R., Clark, B. C., Cesari, M., & Johnson, C. (2021). Handgrip strength asymmetry is associated with future falls in older Americans. Aging Clinical and Experimental Research, 33(9), 2461-2469. https://doi.org/10.1007/s40520-020-01757-z
  29. McGrath, R. P., Kraemer, W. J., Snih, S. A., & Peterson, M. D. (2018). Handgrip strength and health in aging adults. Sports Medicine, 48(5), 1059–1062. https://doi.org/10.1007/s40279-018-0952-y
  30. McGrath, R., Lang, J., Clark, B.C., Cawthon, P.M., Black, K., Kieser, J., Fraser, B.J., & Tomkinson, G.R. (2023). Prevalence and trends of handgrip strength asymmetry in the United States. Advances in Geriatric Medicine and Research, 5(2), e230006. https://doi.org/10.20900/agmr20230006
  31. McGrath, R., Vincent, B.M., Hackney, K.J., Robinson-Lane, S.G., Downer, B., & Clark, B.C. (2020). The longitudinal associations of handgrip strength and cognitive function in aging Americans. Journal of the American Medical Directors Association, 21(6), 634-639.e1. https://doi.org/10.1016/j.jamda.2019.08.032
  32. McNeil, C.J., & Rice, C.L. (2018). Neuromuscular adaptations to healthy aging. Applied Physiology, Nutrition, and Metabolism, 43(4), 307–317. https://doi.org/10.1139/apnm-2018-0327
  33. Moritani, T. (1993). Neuromuscular adaptations during the acquisition of muscle strength, power, and motor tasks. Journal of Biomechanics, 26(1), 95–107. https://doi.org/10.1016/0021-9290(93)90082-P
  34. Neri, S.G.R., Lima, R.M., Ribeiro, H.S., & Vainshelboim, B. (2021). Poor handgrip strength determined clinically is associated with falls in older women. Journal of Frailty, Sarcopenia and Falls, 6(2), 43-49. https://doi.org/10.22540/JFSF-06-043
  35. Norman, K., Stobäus, N., Gonzalez, M.C., Schulzke, J.D., & Pirlich, M. (2011). Hand grip strength: Outcome predictor and marker of nutritional status. Clinical Nutrition, 30(2), 135–142. https://doi.org/10.1016/j.clnu.2010.09.010
  36. Orchard, S.G., Polekhina, G., Ryan, J., Shah, R.C., Storey, E., Chong, T.T., Lockery, J.E., Ward, S.A., Wolfe, R., Nelson, M.R., Reid, C.M., Murray, A.M., Espinoza, S.E., Newman, A.B., McNeil, J.J., Collyer, T.A., Callisaya, M.L., Woods, R.L., & ASPREE Investigator group. (2022). Combination of gait speed and grip strength to predict cognitive decline and dementia. Alzheimer’s & Dementia, 14(1), e12353. https://doi.org/10.1002/dad2.12353
  37. Pierle, C., McDaniel, A.T., Schroeder, L.H., Heijnen, M.J.H., & Tseh, W. Efficacy of a 6-Week suspension training exercise program on fitness components in older adults. International Journal of Exercise Science, 15(3), 1168–78, https://doi.org/10.70252/GPEB7735
  38. Santanasto, A.J., Glynn, N.W., Lovato, L.C., Blair, S.N., Fielding, R.A., Gill, T.M., Guralnik, J.M., Fang-Chi, H., King, A.C., Strotmeye, E.S., Manini, T.M., Marsh, A.P., McDermott, M.M., Goodpaster, B.H., Pahor, M., Newman, A.B., & LIFE Study Group. (2017). Effect of physical activity versus health education on physical function, grip strength and mobility. Journal of the American Geriatrics Society, 65(7), 1427–1433. https://doi.org/10.1111/jgs.14804
  39. Sarikaya, P.M., Incel, N.A., Yilmaz, A., & Cimen, O.B. (2017). Effect of hand dominance on functional status and recovery of hand in stroke patients. Science, 6(3), 39-45. https://doi.org/10.11648/j.sjcm.20170603.12
  40. Shiba, J., & Lizarraga, J. (2020). The effects of laterality card training on non-dominant hand grip strength compared to traditional hand grip strengthening exercises. ProQuest Dissertations. Retrieved from https://search.proquest.com/openview/d14677df9d3c3a2d1f3227defc22bc9f/1
  41. Skelton, D.A., Young, A., Greig, C.A., & Malbut, K.E. (1995) Effects of resistance training on strength, power, and selected functional abilities of women aged 75 and older. Journal of the American Geriatrics Society, 43(10), 1081–1087. https://doi.org/10.1111/j.1532-5415.1995.tb07004.x
  42. Szulc, P., Feyt, C., & Chapurlat, R. (2016). High risk of fall, poor physical function, and low grip strength in men with fracture-the STRAMBO study. Journal of Cachexia, Sarcopenia and Muscle, 7(3), 299–311. https://doi.org/10.1002/jcsm.12066
  43. Thomas, E.M., & Sahlberg, M. (2008). The effect of resistance training on handgrip strength in young adults. Isokinetics and Exercise Science, 16(3), 159–165. https://doi.org/10.3233/IES-2008-0307
  44. Tung, H., Chen, K., Chou, C., Belcastro, F., Hsu, H., & Kuo, C. (2023). Acupunch exercise improved muscle mass, hand grip strength, and sleep quality of institutional older adults with probable sarcopenia. Journal of Applied Gerontology, 42(5), 888–97. https://doi.org/10.1177/07334648221141413
  45. Watermeyer, T., Massa, F., Goerdten, J., Stirland, L., Johansson, B., & Muniz-Terrera, G. (2021). Cognitive dispersion predicts grip strength trajectories in men but not women in a sample of the oldest old without dementia. Innovation in Aging, 5(3), igab025. https://doi.org/10.1093/geroni/igab025
  46. Winger, M.E., Caserotti, P., Cauley, J.A., Boudreau, R.M., Piva, S.R., Cawthon, P.M., Orwoll, E.S., Ensrud, K.E., Kado, D.M., Strotmeyer, E.S., & Osteoporotic Fractures in Men (MrOS) Research Group (2023). Lower leg power and grip strength are associated with increased fall injury risk in older men: the osteoporotic fractures in men study. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 78(3), 479–485. https://doi.org/10.1093/gerona/glac122

2025-05-23T11:26:33-05:00June 13th, 2025|Research, Sport Education, Sport Training, Sports Coaching, Sports Exercise Science, Sports Health & Fitness, Sports Medicine|Comments Off on Efficacy of 12-Week Handgrip Strength Training Program Amongst Older Adults: A Pilot Study 
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Correlation Between Post-Injury Mental Health Symptoms and Rehabilitation Adherence in Collegiate Athletes

Authors:

Luis Torres1, Fredrick A. Gardin2, Shala E, Davis3, and Colleen A. Shotwell4

Corresponding Author: 

Luis Torres

1 Normal Avenue.,

Montclair, NJ 07043

[email protected]
.

Correlation Between Post-Injury Mental Health Symptoms and Rehabilitation Adherence in Collegiate Athletes

Purpose: To explore the correlation between post-injury mental health symptoms and rehabilitation adherence in collegiate athletes to gain knowledge that would improve rehabilitative recommendations. Methods: 19 National Collegiate Athletic Association athletes (M age: 20.58 ± 1.31) were assessed for depressive and anxious symptoms using the Hospital Anxiety and Depression Scale (HADS) after injury. Once they were cleared for full sports participation, they were administered the HADS again and the Rehabilitation Adherence Questionnaire (RAQ) to measure their perceptions of adherence to their rehabilitation programs. Results: A significant correlation was found between the two administrations of the HADS (R = .55, P = .03), but no significant correlations were found between RAQ scores and any of the HADS scores. Conclusions: Although the findings of this study did not establish a significant correlation between post-injury depression and anxiety symptoms and self-perceptions of rehabilitation adherence, strong evidence still exists to believe that poor mental health may be associated with poor rehabilitation adherence. Applications in Sport: Members of the collegiate athlete care team should be aware that the common underreporting of mental health symptoms in this population might make it difficult to establish the relationship between these symptoms and their recovery process after an injury. A holistic recovery approach should be considered in any injury recovery processes to allow collegiate athletes to heal both physically and psychologically.

Keywords: depression, anxiety, injury, recovery

Abbreviations: NCAA, National Collegiate Athletic Association; HADS, Hospital Anxiety and Depression Scale; RAQ, Rehabilitation Adherence Questionnaire  
Introduction
Depression and anxiety remain as the leading mental health conditions among collegiate athletes, with as many as 30% and 50% of National Collegiate Athletic Association (NCAA) athletes reporting depression and anxiety, respectively, in a 2011 survey from the National College Health Association (NCAA, 2024). More recently, the American College of Sports Medicine (2024), in their 2021 statement on mental health challenges for athletes, found that the prevalence for depression and/or anxiety in this population ranges between 25% to 35% and only 10% of collegiate athletes with a known mental health condition seek help from a mental health professional. The reasons for this prevalence are multi-faceted given that collegiate athletes often maintain a strong athletic identity that is reluctant to ask for help and are faced with the societal perception of athletes always having to be immensely resilient during all hardships (Chang et al., 2020; Sarac et al., 2018; Tomalski et al., 2019; Wayment et al., 2017; Weigard et al., 2012; Wolanin et al., 2016). Collegiate athletes balance academic demands with their time-intensive and stress-inducing athletic demands while encountering issues relevant to sexuality, gender, hazing, bullying, sexual misconduct, body image, and sport transition (Greenleaf et al., 2009; Petrie et al., 2008; Putukian, 2016). The notion that athletes may be at a decreased risk for mental health conditions due to increased levels of exercise and other personality traits that can aid in athletic success has been shown to be a misconception (Chang et al., 2020). Furthermore, collegiate athletes are exposed to an abundance of additional unique risk factors for depression and anxiety when compared to non-athlete collegiate student counterparts (Demirel, 2016; Ghaedi et al., 2014; Hagiwara et al., 2017; Hanton et al., 2013; McGuire et al., 2017).

Unfortunately, sports injury is an often unavoidable element of collegiate athletics participation, with approximately 40% to 50% of collegiate athletes sustaining at least 1 injury requiring either medical attention or a participation restriction during their careers (Yang et al., 2014b). Injuries such as ligamentous sprains, muscular strains, skeletal fractures, joint dislocations, and concussions are relatively common (Yang et al., 2014a). Sports injuries further aggrandize the preexisting symptoms of depression and anxiety present in collegiate athletes due to the fact that a sports injury may serve as potentially one of the most physically and emotionally disturbing events that a collegiate athlete may experience during their career. Injured collegiate athletes experience enhanced risk factors of depression and anxiety such as fear of reinjury, trouble sleeping, poor concentration, emotional numbness, and injury conversation avoidance (Li et al., 2017; Padaki et al., 2018). They utilize the coping mechanisms of unrealistic wishful thinking, unhealthy venting of emotions, denial, and behavior disengagement (Wadey et al., 2014). Additively, social stressors and financial stressors have also been shown to substantially grow post-injury in collegiate athletes (Evans et al., 2012). Despite these complications, however, collegiate athletes are often still expected to adhere to sports rehabilitation exercise programs for a full recovery and timely return-to-sport.

Sports rehabilitation exercise programs are only effective for collegiate athletes when they are closely adhering to the instructions provided to them by their rehabilitative healthcare provider (Torres et al., 2023a). Poor rehabilitation adherence may prolong recovery, enhance reinjury risk, and reduce the likelihood of positive patient outcomes upon return-to-sport (Jack et al., 2010). The salient post-injury symptoms of depression and anxiety play a role in reducing rehabilitation adherence and hindering injury recovery in collegiate athletes (Baez et al., 2023; Torres et al., 2023b). However, given that as many as 98.3% of injured collegiate athletes have been reported to either overadhere and underadhere to their rehabilitation programs, more contemporary evidence is needed to further understand this extent of this role (Granquist et al., 2014). Despite the recent progress in collegiate athlete mental health screening that has been made, rehabilitative healthcare providers of injured collegiate athletes may not yet be collectively appropriately aware of the symptoms of depression and anxiety in rehabilitation. The purpose of this study was to explore the correlation between post-injury depression and anxiety and rehabilitation adherence in collegiate athletes in an effort to gain knowledge that would improve recommendations for sports rehabilitation programs.
Methods

Sampling
The sampling in this study was limited to two collegiate institutions of varying NCAA competition levels (NCAA Division II and NCAA Division III) within the Mid-Atlantic region of the United States. Demographic information on age, sex, NCAA competition level, race/ethnicity, academic eligibility level, type of sport, and type of musculoskeletal injury was collected from all participants. Participants were recruited by their athletic trainers after a sports injury had occurred and were included based on being 18 years of age or older and sustaining an acute musculoskeletal sports injury that required the inability to engage in full sports participation for at least four weeks. The purpose of this four week requirement was to ensure that the injuries sustained were significant enough to require a rehabilitation program for at least a month (Shin et al., 2010). Collegiate athletes were excluded if they had a concussion, respiratory disease, metabolic disease, cardiac disease, autonomic nervous system disease, or chronic injury of an unknown origin.
Instrumentation

Zigmond and Snaith (1983) designed the Hospital Anxiety and Depression Scale (HADS) as a 14-item questionnaire to measure the symptoms of depression and anxiety. The HADS consists of two subscales that are constructed of seven items for symptoms of depression (HADS-D) and seven items for symptoms of anxiety (HADS-A). Each item contains responses that are individually scored on a scale from 0 to 3 with higher scores indicating a higher level of symptom frequency (i.e., not at all, sometimes, occasionally very often, nearly all the time, etc.). The combined score of emotional distress (sum of HADS-A and HADS-D) ranges from 0 to 42 with scores of 11 or higher indicating a potential for a clinically significant mood disorder case. The total score of each participant places them into one of the following categories: non-case/normal (0 – 7), borderline case/borderline abnormal (8-10), case/abnormal (11 – 21+). Correlations ranging from .76 to .41 for the seven anxiety items (P < .01) and from .60 to .30 for the seven depression items (P < .02) have been associated with this instrument (Zigmond & Snaith, 1983). Similarly, calculated Spearman correlations between subscale scores and confirmed psychiatric ratings have shown that R = .70 for HADS-D and R = .74 for HADS-A (P < .001). The HADS has been routinely established as an instrument that performs well in assessing the symptom severity and caseness of depression and anxiety in both psychiatric and primary care patients and the general population (including collegiate athletes) (Bjelland et al., 2002).

RAQ
Fisher et al. (1988) designed the Rehabilitation Adherence Questionnaire (RAQ) as a 40-item questionnaire to measure rehabilitation adherence, while Shin et al. (2010) later redeveloped the RAQ into a 25-item questionnaire and validated it for injured athletes. The RAQ consists of six subscales: support from significant others (five items), pain tolerance (five items), scheduling (four items), self-motivation (five items), perceived exertion (three items), and environmental conditions (three items), and participants using the RAQ rate their level of agreement to each item using a four-point scale (i.e., 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). The responses to each statement are then summed for a total adherence score that can range from 25 – 100. Higher total adherence scores indicate that participants perceive themselves successfully adhering to and completing their rehabilitation programs as prescribed by their rehabilitative healthcare provider. Moderate to high intra-class correlation coefficients for the each of the six subscales (support from significant others = .81, pain tolerance = .64, scheduling = .72, self-motivation = .78, perceived exertion = .67, and environmental conditions = .82; P < .01) have been found for this instrument, thus indicating a high level of test-retest reliability within the RAQ (Shin et al.).

Data Collection
A non-experimental repeated-measures prospective cohort study design was used in the completion of this study. Human subjects research approval was provided from the East Stroudsburg University Institutional Review Board (protocol #ESU-IRB-041-2021) in March of 2021, with the data collecting period for this study starting in June of 2021 and ending in February of 2022. After an in-season sports injury had occurred, collegiate athletes who met the appropriate inclusion criteria were approached by their athletic trainer for voluntary participation in this study through the provision of an electronic informed consent form on their first full day of starting their rehabilitation programs. The collegiate athletes were made aware that their involvement in this study would not have any effect on their status as a student-athlete at their respective institution. Once enrolled in the study, the participants were asked to complete the HADS to measure their current post-injury depression and anxiety symptoms. Participants were then monitored throughout the duration of their rehabilitation programs until they received clearance for full sports participation from either their team physician and/or athletic trainer (i.e., at return-to-play). On the day this clearance was attained, the HADS was administered again as well as the RAQ to measure their self-perceptions of their adherence to their rehabilitation programs. All questionnaires in this study were administered through Health Insurance Portability and Accountability Act (HIPAA) compliant Google Forms on either a password-protected tablet, smartphone, or computer desktop with all collected data being deidentified, kept confidential, and stored in a password-encrypted computer.

Data Analysis
The IBM SPSS 27.0 Statistical Package was used to analyze all collected data once the data collection period was complete. Descriptive statistics were reported and Pearson product-moment correlation tests with a significance level of P < .05 were conducted among HADS and RAQ scores to attempt to further identify the relationships between post-injury depression and anxiety and rehabilitation adherence in collegiate athletes. The following criteria were used to interpret R values: little to no relationship (.00–.25), fair relationship (.25–.50), moderate to good relationship (.50–.75), and good to excellent relationship (above .75) (Portney & Watkins, 2009).
Results

The 19 participants (M age: 20.58 ± 1.31; 17 males, 2 females) in this study were primarily NCAA Division II student-athletes (73.7%), White Caucasian (63.2%), academic seniors (42.1%), and football athletes (63.2%). The participants sustained various musculoskeletal conditions such as foot/ankle injuries (36.8%), knee injuries (21.1%), hip/thigh injuries (21.1%), and shoulder injuries (21.1%) with three participants not being cleared for a return to full sports participation at the conclusion of the data collection period. The cleared participants (n = 16) took 96.63 ± 31.90 days to recover from their sustained injuries before they were cleared for full sports participation. For the completion of the post-injury HADS (i.e., HADS 1 administration), the participants (n = 19) scored an 11.58 ± 5.26, while for the completion of the return-to-play HADS (i.e., HADS 2 administration), the participants (n = 16) scored a 9.63 ± 5.83. The participants (n = 15) rated their self-perception of rehabilitation adherence to be 57.20 ± 4.95 on a scale of 25 to 100 using the RAQ. A significant positive correlation was found between HADS 1 and HADS 2 scores (R = .55, P = .03), but no significant correlations were found between RAQ and HADS 1 scores (R = .52, P = .85) or RAQ and HADS 2 scores (R = .14, P = .63).

Discussion
The mean scores of both HADS 1 and HADS 2 falling above the asymptomatic normal HADS category indicates that depressive and anxious symptoms remain a substantial presence for collegiate athletes at post-injury and return-to-play states. Furthermore, although the findings of this study did not establish a significant correlation between post-injury depression and anxiety symptoms and self-perceptions of rehabilitation adherence, there is still strong existing evidence from previous researchers to believe that poor mental health may be associated with poor rehabilitation adherence. Holt et al. (2019) organized a literature review of 34 studies on the topic of adherence to exercise therapy interventions in children and adolescents with musculoskeletal conditions among 6 different databases. The selected studies represented 1,563 participants (35% male, 65% female, 2-19 years old), 11 musculoskeletal conditions, and multiple exercise interventions. Commonly identified barriers to rehabilitation adherence in this review included time constraints, physical environment (location), and previous negative exercise experiences. Holt et al. concluded that a diversity of barriers and facilitators to exercise therapy for musculoskeletal conditions exist and current strategies to boost adherence are not consistent with contemporarily identified barriers and facilitators. They clinically referenced that making exercise enjoyable, social, and convenient may be important to maximizing rehabilitation adherence to exercise therapy in young, injured athletes.

Jack et al. (2010) developed a systematic review of 22 articles reporting on 20 independent cohort studies using the ADMED, CINAHL, EMBASE, MEDLINE, PUBMED, PSYCINFO, SPORTDISCUS, Cochrane Central Register of Controlled Trials, and PEDro databases to understand the barriers to treatment adherence in physiotherapy outpatient clinics. These researchers identified high quality studies that maintained a focus on the exploration of rehabilitation adherence in patients with musculoskeletal conditions. They found that there was strong evidence to indicate that poor treatment adherence was associated with low levels of physical activity at baseline or in previous weeks, low in-treatment adherence with exercise, low self-efficacy, depression, anxiety, helplessness, poor social support, greater number of perceived barriers to exercise, and increased pain levels during exercise. They also found that the research focused on the ability of health professionals and health organizations to address these barriers was comparatively limited. Holt et al. (2019) and Jack et al. would agree that symptoms of depression and anxiety may negatively influence rehabilitation adherence and that future study on the barriers to rehabilitation adherence is essential to the development of useful interventions by sports medicine professionals and other healthcare providers.

Brewer et al. (2013) studied the predictors of adherence to home rehabilitation exercises following ACL reconstruction in a study of 91 (58 males, 33 females) post-operative patients. These patients completed measures of athletic identity, neuroticism, optimism, and pessimism before ACL surgery and measures of daily pain, negative mood, stress, and home exercise completion for 42 days postoperatively. These researchers found that their participants reported high levels of adherence to the prescribed exercise regimen and that the participants completed fewer home exercises on days when they experience more stress or negative moods. They concluded that day-to-day variations in negative mood and stress may contribute to adherence to prescribed home exercises. This conclusion may be generalizable to athletic training settings in collegiate athletics, as past studies have supported the presence of poor rehabilitation adherence by student-athletes in these settings (Granquist et al, 2014; Fisher et al., 1988).

Evans et al. (2012) researched the stressors experienced by injured athletes during the 3 phases of their recovery from sports injury (onset, rehabilitation, return to play) and the differences in the stressors experienced by team-sport athletes as compared to individual-sport athletes with the use of semi structured interviews. The sample in this study consisted of 5 previously injured high-level rugby players and five previously injured high-level golfers. These researchers found that the athletes in their study experienced sport, medical/physical, and social and financial stressors; they also found that these same athletes reported several differences in the stressors experienced across the 3 phases of injury recovery and between team and individual-sport athletes. These researchers stressed that their findings have important implications for the design and implementation of interventions aimed at managing the potentially stressful sport injury experience and facilitating the return of injured athletes to competitive sport. This research supports the notion that certain psychosocial components of sports injury affect the ability of collegiate athletes to return to sports participation without any limitations.

Wadey et al. (2014) explored the relationship between re-injury anxiety and return-to-play outcomes in a cross-sectional research study of 335 collegiate athletes (M age = 23.5 ± 6.6) from varying NCAA competition levels. The athletes in this study completed the RIA-RE subscale of the Reinjury Anxiety Inventory (RIAI) as an assessment of reinjury anxiety and the Return to Sport After Serious Injury Questionnaire (RSSIQ) as an assessment of the perceptions of athletes on returning to sport. These researchers also assessed the presence of coping strategies in these athletes with the use of the Crocker and Graham MCOPE measure. They found a positive relationship between re-injury anxiety and heightened return concerns (R = .62, P < .01) and significant indirect effects for coping were found for wishful thinking, venting of emotions, denial, and behavioral disengagement. They suggested that future researchers should continue to examine the relationship between anxiety and return-to-play outcomes using diverse methodologies.

Conclusions
With the premise that poor mental health may be correlated to poor rehabilitation adherence, it is reasonable to suggest that rehabilitative healthcare providers should have an invested interest in utilizing effective psychosocial interventions within their programming when treating injured collegiate athletes. Additionally, they should re-evaluate their own mental health screening practices to ensure that they are screening for appropriate mental health symptoms at baseline, at post-injury, and at return-to-play, as this is now considered best practice (Baez & Jochimsen, 2023). Rehabilitative healthcare providers should also be keenly aware of the fact that underreporting and a proven reluctance to ask for help in this population may play a role in masking certain symptoms through the entire rehabilitative process. These same elements may have also played a role as to why a relationship was not established between post-injury depression and anxiety symptoms and self-perceptions of rehabilitation adherence in this study. Other study limitations, including a small, predominantly White and male sample, timing and scheduling issues in the athletic training facility, and a lack of standardization when it came to the rehabilitation programs prescribed by the athletic trainers, could also have impacted the results. Future researchers should seek to create similar studies with much larger, diverse sample sizes that explore correlations between the individual subscales of HADS-D and HADS-A and the self-perceptions of rehabilitation adherence of collegiate athletes.

Applications in Sport
Members of the collegiate athlete care team, such as coaches, athletic trainers, and other healthcare providers, should be aware that the common underreporting of mental health symptoms in this population might make it difficult to establish the relationship between these symptoms and their recovery process after an injury. A holistic recovery approach should be considered in any injury recovery processes to allow collegiate athletes to heal both physically and psychologically. Despite their inability to sometimes be vulnerable and transparent in reporting, collegiate athletes clearly struggle with their mental health and more research is needed to better understand how the more nuanced aspects of depressive, anxious, and disordered eating symptomatology affect them while they are recovering from a sports injury. The best collegiate athletic environments are those that permit collegiate athletes to report any and all mental health symptoms, concerns, and crises without any fear of consequences stemming from coaches and other relevant personnel.

1.Baez, S., & Jochimsen, K. (2023). Current clinical concepts: integration of psychologically  informed practice for management of patients with sport-related injuries. Journal of Athletic Training, 58(9), 687-696. https://doi:10.4085/1062-6050-0556.22

2.Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the hospital anxiety and depression scale: an updated literature review. Journal of Psychosomatic Research, 52, 69-77.

3.Brewer, B. W., Cornelius, A. E., Van Raalte, J. L., Tennen, H., & Armeli, S. (2013). Predictors of adherence to home rehabilitation exercises following anterior cruciate ligament reconstruction. Rehabilitation Psychology, 58(1), 64-72. https://doi:10.1037/a0031297

4.Chang, C., Putukian, M., Aerni, G., Diamond, A., Hong, G., Ingram, Y., Reardon, C. L., & Wolanin, A. (2020). Mental health issues and psychological factors in athletes: detection, management, effect on performance and prevention: American Medical Society for Sports Medicine position statement – executive summary. British Journal of Sports Medicine, 54(4), 216-220. https://doi:10.1136/bjsports-2019-101583

5.Demirel, H. (2016). Have university sports students higher scores depression, anxiety, and psychological stress? International Journal of Environmental & Science Education,

11(16), 9422-9425.

6.Evans, L., Wadey, R., Hanton, S., & Mitchell, I. (2012). Stressors experienced by injured athletes. Journal of Sports Sciences, 30(9), 917-927. http://dx.doi.org/10.1080/02640414.2012.682078

7.Fisher, A. C., Domm, M. A., & Wuest, D. A. (1988). Adherence to sports-injury rehabilitation programs. The Physician and Sportsmedicine, 16(7), 47-52. http://dx.doi.org/10.1080/00913847.1988.11709551

8.Ghaedi, L., & Mohd, A. (2014). Prevalence of depression among undergraduate students: gender and age differences. International Journal of Psychological Research, 7(2), 38-50.

9.Granquist, M. D., Podlog, L., Engel, J. R., & Newland, A. (2014). Certified athletic trainers’ perspectives on rehabilitation adherence in collegiate athletic training settings. Journal of Sport Rehabilitation, 23, 123-133. http://dx.doi.org/10.1123/JSR.2013-0009

10.Greenleaf, C., Petrie, T. A., Carter, J., & Reel, J. J. (2009). Female collegiate athletes: prevalence of eating disorders and disordered eating behaviors. Journal of American College Health, 57(5), 489-496. doi:10.3200/JACH.57.5.489-496

11.Hagiwara, G., Iwatsuki, T., Isogai, H., Van Raalte, J. L., & Brewer, B. W. (2017). Relationships among sports helplessness, depression, and social support in American college student-athletes. Journal of Physical Education and Sport, 17(2), 753-757.

12.Hanton, S., Neil, R., & Evans, L. (2013). Hardiness and anxiety interpretation: an investigation into coping usage and effectiveness. European Journal of Sport Science, 13(1), 96-104. http://dx.doi.org/10.1080/17461391.2011.635810

13.Holt, C. J., McKay, C. D., Truong, L. K., Le, C. Y., Gross, D. P., & Whitaker, J. L. (2019). Sticking to it: a scoping review of adherence to exercise therapy interventions in children and adolescents with musculoskeletal disorders. International Journal of Sports Physical Therapy, 14(6), 14.

14.Jack, K., McLean, S. M., Moffett, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual Therapy, 15, 220-228. doi:10.1016/j.math.2009.12.004

15.Li, H., Moreland, J., Peek-Asa, C., & Yang, J. (2017). Preseason anxiety and depressive symptoms and prospective injury risk in collegiate athletes. American Journal of Sports Medicine, 45(9), 2148-2155. https://doi.org/10.1177/0363546517702847

16.McGuire, L. C., Ingram, Y. M., Sachs, M. L., & Tierney, R. T. (2017). Temporal changes in depression symptoms in male and female collegiate student-athletes.

17.Journal of Clinical Sport Psychology, 11, 337-351. https://doi.org/10.1123/JCSP.2016-0035 National Collegiate Athletic Association. (2024). Mind, body, and sport: depression and anxiety prevalence in student-athletes. Retrieved May 26, 2024, from https://www.ncaa.org/sports/2014/10/8/mind-body-and-sport-depression-and-anxiety-prevalence-in-student-athletes.aspx

18.Padaki, A. S., Noticewala, M. S., Levine, W. N., Ahmad, C. S., Popkin, M. K., Popkin, C. A. (2018). Prevalence of posttraumatic stress disorder symptoms among young athletes after anterior cruciate ligament rupture. Orthopaedic Journal of Sports Medicine, 6(7), 1-5. https://doi.org/10.1177/2325967118787159

19.Petrie, T. A., Greenleaf, C., Reel, J. J, & Carter, J. (2008). Prevalence of eating disorders and disordered eating behaviors among male collegiate athletes. Psychology of Men & Masculinity, 9(4), 267-277. doi:10.1037/a0013178

20.Portney, L. G, & Watkin, M. P. (2009). Foundations of Clinical Research: Applications to Practice (3rd ed.). Pearson.

21.Putukian, M. (2016). The psychological response to injury in student athletes: a narrative review with a focus on mental health. British Journal of Sports Medicine, 50, 145-149. https://doi.org/10.1136/bjsports-2015-095586

22.Sarac, N., Sarc, B., Pedroza, A., Borchers, J. (2018). Epidemiology of mental health conditions in incoming division I collegiate athletics. The Physician and SportsMedicine, 46(2), 242-248. https://doi:10.1080/00913847.2018.1427412

23.Shin, J., Park, R., Song, W., Kim, S., & Kwon, S. (2010). The redevelopment and validation of the rehabilitation adherence questionnaire for injured athletes. International Journal of Rehabilitation Research, 33, 64-71. doi:10.1097/MRR.ob013e32832fea39

24.The American College of Sports Medicine. (2024). The American college of sports medicine statement on mental health challenges for athletes. Retrieved May 26, 2024, from https://www.acsm.org/news-detail/2021/08/09/the-american-college-of-sports- medicine-statement-on-mental-health-challenges-for-athletes

25.Tomalski, J., Clevinger, K., Albert E., Jackson, R., Wartalowicz, K., & Petrie, T. A. (2019). Mental health screening for athletes: program development, implementation, and evaluation. Journal of Sports Psychology in Action, 10(2), 121-135. https://doi.org/10.1080/21520704.2019.1604589

26.Torres L., Davis, S. E., Shotwell, S. A, & Gardin, F. A. (2024a). Disagreement of rehabilitation adherence perceptions among athletic trainers and injured collegiate athletes. International Journal of Athletic Therapy and Training, 29,(4), 208-212. https://doi:10.1123/ijatt.2023-0043.

27.Torres, L., Davis, S. E, Shotwell, C.A, & Gardin, F. A. (2023b). Effect of depression and anxiety in rehabilitation adherence and injury recovery in collegiate athletes. Journal of Sports Medicine and Allied Health Sciences, 9(2), 1-12.

28.Wadey, R., Podlog, L., Hall, M., Hamson-Utley, J., Hicks-Little, C., & Hammer, C. (2014). Reinjury anxiety, coping, and return-to-sport outcomes: a multiple mediation analysis. Rehabilitation Psychology, 59(3), 256-266. http://dx.doi.org/10.1037/a0037032

29.Wayment H. A. & Walters, A. S. (2017). Goal orientation and well-being in collegiate athletes: the importance of athletic social connectedness. Journal of Sports Science, 35(21). https://doi:10.1080/02640414.20161257147

30.Weigard, S., Cohen J., & Merenstein, D. (2012) Susceptibility for depression in current and retired student athletes. Sports Health, 5(3), 263-266. https://doi:10.1177/1941738113480464

31.Wolanin, A., Hong, E., Marks, D., Panchoo, K., & Gross, M. (2016). Prevalence of clinically elevated depressive symptoms in college athletes and differences by gender and sport. British Journal of Sports Medicine, 50, 167-171. https://doi.org/10.1136.bjsports-2015-095756

32.Yang, J., Cheng, G., Zhang, Y., Covassin, T., Heiden, E., & Peek-Asa C. (2014a). Influence on symptoms of depression and anxiety on injury hazard among collegiate American football players. Research in Sports Medicine, 22, 147-160. https://doi.org/10.1080/15438627.2014.881818

33.Yang, J., Schaefer, J. T., Zhang, N., Covassin, T., Ding, K., & Heiden, E. (2014b). Social support from the athletic trainer and symptoms of depression and anxiety at return to play. Journal of Athletic Training, 49(6), 773 – 779. https://doi.org/10.4085/1062-6050-49.3.65

34.Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatric Scandinavica, 67, 361-370.

2025-03-26T12:17:32-05:00April 4th, 2025|Sports Medicine|Comments Off on Correlation Between Post-Injury Mental Health Symptoms and Rehabilitation Adherence in Collegiate Athletes
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