The acute-to-chronic workload ratio: an inaccurate scaling index for an unnecessary normalisation process?

Stress Drives Soccer Athletes' Wellness and Movement: Using Convergent Cross-Mapping to Identify Causal Relationships in a Dynamic Environment

PURPOSE

Prediction of athlete wellness is difficult-or, many sports-medicine practitioners and scientists would argue, impossible. Instead, one settles for correlational relationships of variables gathered at fixed moments in time. The issue may be an inherent mismatch between usual methods of data collection and analysis and the complex nature of the variables governing athlete wellness. Variables such as external load, stress, muscle soreness, and sleep quality may affect each other and wellness in a dynamic, nonlinear, way over time. In such an environment, traditional data-collection methods and statistics will fail to capture causal effects. If we are to move this area of sport science forward, a different approach is required.

METHODS

We analyzed data from 2 different soccer teams that showed no significance between player load and wellness or among individual measures of wellness. Our analysis used methods of attractor reconstruction to examine possible causal relationships between GPS/accelerometer-measured external training load and wellness variables.

RESULTS

Our analysis showed that player self-rated stress, a component of wellness, seems a fundamental driving variable. The influence of stress is so great that stress can predict other components of athlete wellness, and, in turn, self-rated stress can be predicted by observing a player's load data.

CONCLUSION

We demonstrate the ability of nonlinear methods to identify interactions between and among variables to predict future athlete stress. These relationships are indicative of the causal relationships playing out in athlete wellness over the course of a soccer season.

Practitioners' perspective of non-contact injury risk factors and injury prevention programming in professional North American male soccer

OBJECTIVE

To evaluate non-contact injury prevention strategies of professional men's soccer clubs in elite North American league soccer. To understand the application, perceived effectiveness and barriers to implementation.

DESIGN

Online cross-Sectional Study.

SETTING

North American elite soccer teams.

PARTICIPANTS

96 medical and performance support staff of elite North American teams.

MAIN OUTCOME MEASURE

The survey consisted of 20 questions and captured 1) practitioners' demographics; 2) perceptions of risk factors; 3) the use of assessment and monitoring strategies; and 4) perceptions of the implementation of injury prevention programmes'.

RESULTS

Injury prevention programmes were perceived as 'effective' (Median 4, Interquartile range 4-4) and reduced injury rates (n = 94, 98%, 95 CI% 93 to 99). A range of potential risk factors were rated as "very important" (4.58 ± 0.52 Likert scale points; mean ± standard deviation). A multi-disciplinary approach to the design, application and monitoring of programmes was generally adopted. Competing training priorities (n = 75, 78%, 95 CI% 69 to 85) and game schedules (n = 71, 74%, 95 CI% 64 to 82) were the most prevalent barriers to injury prevention implementation.

CONCLUSIONS

Injury prevention programmes were perceived as effective in reducing non-contact injuries. Managing the conflicting priorities between scheduling training, tactical and conditioning goals were considered the key barriers to desired implementation.

Causal inference did not detect any effect of jump load on knee complaints in elite men's volleyball

The aim was to determine how jump load affects knee complaints in elite men's volleyball. We collected data from four men's premier league volleyball teams through three seasons in a prospective cohort study (65 players, 102 player-seasons). Vert inertial measurement devices captured the jump load (jump frequency and jump height) from 21 088 daily player sessions, and knee complaints were reported in 3568 weekly OSTRC-O questionnaires. Mixed complementary log-log regression models described the probability of (i) experiencing symptoms if players were currently asymptomatic, (ii) worsening symptoms if players had symptoms, and (iii) recovery from knee complaints. Based on our causal assumptions, weekly jump load was modeled as the independent variable, adjusted for age (years), weight (kg), position on volleyball team, and past jump load. No certain evidence of an association was found between weekly jump load and probability of (i) knee complaints (p from 0.10 to 0.32 for three restricted cubic splines of load), (ii) worsening symptoms if the player already had symptoms (p from 0.11 to 0.97), (iii) recovery (p from 0.36 to 0.63). The probability of knee complaints was highest for above-average weekly jump load (~1.2% for an outside hitter with mean age and height) compared with low loads (~1%) and very high loads (→ ~ 0%). The association between jump load and knee complaints risk remains unclear. Small differences in risk across observed jump load levels were observed. It would likely require substantially increased sample sizes to detect this association with certainty.

Healthcare providers have insufficient up-to-date knowledge of lower limb sports injuries, and their knowledge is similar to that of athletes

BACKGROUND

Being up-to-date with evidence-based knowledge of lower limb sports injuries is essential for Healthcare professionals (HCPs).

PURPOSE

To assess whether HCPs possess up-to-date knowledge of lower limb sports injuries by comparing their knowledge to that of athletes.

METHODS

With an expert panel, we developed an online quiz of 10 multiple-choice questions on various topics related to lower-limb sports injuries. Maximal score was 100. We used social media to invite HCPs (5 groups: Physiotherapists, Chiropractors, Medical Doctors, Trainers, and Other therapists) and athletes of all levels (amateur, semi-pro, and pro) to participate. We drafted the questions according to conclusions from the latest systematic reviews and meta-analyses.

RESULTS

1526 participants completed the study. Final quiz scores ranged from zero (n = 28, 1.8%) to 100 (n = 2, 0.1%) and were distributed normally with a mean score of 45.4 ± 20.6. None of the 6 groups' means surpassed the set threshold of 60 points. Multiple linear regressions of covariates indicated that age, gender, engagement in physical activity, learning hours per week, reading scientific journals, reading popular magazines and blogs, trainers, and other therapists' groups explained 19% of the variances (-5.914<β < 15.082, 0.000<p < 0.038).

CONCLUSIONS

HCPs have insufficient up-to-date knowledge of lower limb sports injuries, and their knowledge is similar to that of athletes of all levels. HCPs probably do not possess the proper tools to assess scientific literature Academic and sports medicine societies should look into ways to improve the scientific knowledge integration of HCPs.

Which of the Physiological vs. Critical Speed Is a Determinant of Modern Pentathlon 200 m Front Crawl Swimming Performance: The Influence of Protocol and Ergometer vs. Swimming Pool Conditions

BACKGROUND

Modern pentathlon includes horse riding, fencing, swimming, shooting and cross-country running. Events can last many hours during which the athletes face almost maximal energy and physiological demands, and fatigue. Early recognition and prevention of injuries and overuse syndromes can be achieved by refining the individual training loads. The purpose of the study was to determine which parameter could be the most accurate predictor of swimming working capacity determinants in pentathletes.

METHODS

Fourteen male pentathletes performed a continuous maximal incremental test in the swimming flume ergometer to measure peak oxygen uptake (VO₂peak), and five swimming tests in a 50 m swimming pool to detect critical velocity (CV); velocity at 2 and 4 mM·L^-1 of blood lactate (v2, v4) and energy cost (EC).

RESULTS

The 200 m swimming time was 2:18-2:32 m:s (340 FINA points). CV was 1.21 ± 0.04 m·s^-1, v2 was 1.14 ± 0.09 and v4 1.23 ± 0.08 m·s^-1. VO₂peak was 3540.1 ± 306.2 mL·min^-1 or 48.8 ± 4.6 mL·kg^-1·min^-1. EC at 1.24 m·s^-1 was 45.7 ± 2.4 mL·kg^-1·min^-1. Our main finding was the large correlation of CV with 200 m swimming performance; Conclusions: Among all the protocols analysed, CV is the most predictive and discriminative of individual swimming performance in this group of pentathletes. It appears as the most suitable test to constantly refine their swimming training loads for both performance enhancement and health promotion.

Is Cumulative Load Associated with Injuries in Youth Team Sport? A Systematic Review

Background

High cumulative external and internal load may predispose athletes to increased risk for injury across a variety of sports, competition levels, and age groups. However, evidence of an association between cumulative load and injury in youth sport remains inconclusive. The objective of this study was to determine the current evidence for cumulative load and injury risk relationships in youth team sport through a systematic review of the existing literature.

Methods

A systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Literature searches were conducted in PubMed, Web of Science, SCOPUS, and CINAHL for relevant articles published between January 2010 and April 2021. The authors conducted independent review and quality assessment of the eligible studies. Eleven articles evaluating youth (less than 18 years old) team sport were included for qualitative synthesis.

Results

Fifty-nine percent (n = 39/66) of the relationships assessed revealed an association between cumulative load and injury across the team sports studied, including the presence of load–injury associations in 84% (n = 16/19) of assessments in youth soccer. Of those relationships where an association was present, 79% (n = 31/39) were positive associations between cumulative load and injury. Risk of bias assessment scores ranged from three to six out of seven possible (median = 5) for cohort studies and from four to seven out of 10 possible (median = 5.5) for cross-sectional studies.

Conclusions

There is some evidence for a positive association between load and injury in youth team sport. Youth soccer was the most studied team sport, and a substantial number of positive load–injury associations were reported. Current evidence lacks consistency in the measures and metrics used in defining load–injury relationships.

Trial Registration PRISMA ID - CRD42020203622.

Association of Training and Game Loads to Injury Risk in Junior Male Elite Ice Hockey Players: A Prospective Cohort Study

Background

Training and game loads are potential risk factors of injury in junior elite ice hockey, but the association of training and game loads to injuries is unknown.

Purpose

To investigate the association of chronic training and game loads to injury risk in junior male elite ice hockey players.

Study Design

Cohort study; Level of evidence, 2.

Methods

In this prospective cohort study, we monitored all health problems among 159 male junior ice hockey players (mean age, 16 years; range, 15-19 years) at sports-specific high schools during the 2018-2019 school year. Players reported their health problems every week using the Oslo Sports Trauma Research Center Overuse Questionnaire on Health Problems (OSTRC-H2). The number of training sessions and games was reported for 33 weeks. We calculated the previous 2-week difference in training/game loads as well as the cumulative training/game loads of the previous 2, 3, 4, and 6 weeks and explored potential associations between training/game loads and injury risk using mixed-effects logistic regression.

Results

The players reported 133 acute injuries, 75 overuse injuries, and 162 illnesses in total, and an average of 8.8 (SD ±3.9) training sessions and 0.9 (SD ± 1.1) games per week. We found no association between the difference of the two previous weeks or the previous 2- 3- and 4-week cumulative, training or game load and acute injuries, nor the difference of the two previous weeks, or the previous 4- and 6-week cumulative, training or game load and overuse injuries (OR, ∼1.0; P > .05 in all models).

Conclusion

In the current study of junior elite ice hockey players, there was no evidence of an association between cumulative exposure to training/game loads and injury risk.

The Percentage of Mature Height as a Morphometric Index of Somatic Growth: A Formal Scrutiny of Conventional Simple Ratio Scaling Assumptions

PURPOSE

To assess conventional assumptions that underpin the percentage of mature height index as the simple ratio of screening height (numerator) divided by actual or predicted adult height (denominator).

METHODS

We examined cross-sectional data from 99 academy youth soccer players (chronological age range, 11.5 to 17.7 y) skeletally immature at the screening time and with adult height measurements available at follow-up.

RESULTS

The y-intercept value of -60 cm (95% confidence interval, -115 to -6 cm) from linear regression between screening height and adult height indicated the failure to meet the zero y-intercept assumption. The correlation coefficient between present height and adult height of .64 (95% confidence interval, .50 to .74) was not equal to the ratio of coefficient of variations between these variables (CVx/CVy = 0.46) suggesting Tanner's special circumstance was violated. The non-zero correlation between the ratio and the denominator of .21 (95% confidence interval, .01 to .39) indicated that the percentage of mature height was biased low for players with generally shorter adult height, and vice versa.

CONCLUSION

For the first time, we have demonstrated that the percentage of mature height is an inconsistent statistic for determining the extent of completed growth, leading to potentially biased inferences for research and applied purposes.

Chronic Workload, Subjective Arm Health, and Throwing Injury in High School Baseball Players: 3-Year Retrospective Pilot Study

BACKGROUND

Baseball workloads are monitored by pitch counts, appearances, innings per appearance, ball velocity, and distance, whereas current workload standards neglect throws made during nongame situations. The association between total workloads, subjective measures, and injury in baseball is poorly understood. The question remains whether baseball athletes are at higher risk of injury by throwing more often or if they generate injury resilience when appropriately transitioned into the higher demands of throwing.

HYPOTHESIS

Increased chronic load, along with subjective arm health measures, are related to decreased injury risk.

STUDY DESIGN

Clinical research.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 49 male baseball players (age 17.9 ± 0.4 years, height 181.8 ± 6.8 cm, body mass 80.6 ± 9.1 kg) competing at the varsity high school level were included in this 3-year retrospective data analysis from 2016 to 2019. Players wore the motusTHROW sleeve and sensor during all throwing activities.

RESULTS

A total of 898,492 throws and 9455 athletic exposures were captured with the motusTHROW sensors. There were 24 injuries recorded throughout the 3-year analysis, with 11 throwing-related and 13 non-throwing related injuries. Results of the 1-way analysis of variance found chronic load was significantly related to throwing-injury occurrence (P < 0.01). Six of the throwing-related injuries occurred when athletes had a chronic load greater than 11.3, marking 75th percentile across all observations. There was a relationship between arm health and throwing arm-related injury occurrence (P < 0.01). Higher chronic load was associated with increased throwing-related injuries even when adjusted for arm health (P = 0.01). Specifically, injuries were more likely to occur in pitchers (either as a combination player or pitcher only) with a chronic load greater than 9.2.

CONCLUSION

This study revealed a significant relationship between chronic load, subjective arm health, and throwing-related injury in varsity high school baseball players. Contrary to our hypothesis, increased chronic load was associated with increased injury risk. However, subjective arm health measures remain a relevant factor in assessing injury risk. Normative data for this population also provide key information around positional demands along with overall demands of the sport during the competitive season and off-season.

The Effect of the COVID-19 Lockdown on the Position-Specific Match Running Performance of Professional Football Players; Preliminary Observational Study

The COVID-19 pandemic interrupted professional football in the 2019/2020 season, and football experts anticipate that the consequences of lockdown measures will negatively affect the physical performance of players once competition restarts. This study aimed to evaluate position-specific match running performance (MRP) to determine the effect of COVID-19 lockdowns on the physical performance of professional football players. Players’ MRPs (n = 124) were observed in matches before and after the COVID-19 lockdown in the 2019/2020 season of the highest level of national competition in Croatia and were classified according to player position: central defenders (CD; n = 42), fullbacks (FB; n = 20), midfielders (MF; n = 46), and forwards (FW; n = 16). The MRPs were measured using Global Positioning System, and included the total distance covered, low-intensity running (≤14.3 km/h), running (14.4–19.7 km/h), high-intensity running (≥19.8 km/h), total accelerations (>0.5 m/s²), high-intensity accelerations (>3 m/s²), total decelerations (less than –0.5 m/s²), and high-intensity decelerations (less than –3 m/s²). The results indicated that, in matches after the COVID-19 lockdown, (i) CDs and FBs featured lower running and high-intensity running (t-value: from 2.05 to 3.51; all p < 0.05; moderate to large effect sizes), (ii) MFs covered a greater distance in low-intensity running and achieved a lower number of total accelerations, and total and high-intensity decelerations (t-value: from –3.54 to 2.46; all p < 0.05, moderate to large effect sizes), and (iii) FWs featured lower high-intensity running (t-value = 2.66, p = 0.02, large effect size). These findings demonstrate that the physical performances of football players from the Croatian first division significantly decreased in matches after the COVID-19 lockdown. A combination of inadequate adaptation to football-specific match demands and a crowded schedule after the competition was restarted most likely resulted in such an effect.

Comparison of player-dependent and independent high-speed running thresholds to model injury risk in football

High-speed running (HSR) loads have been linked with non-contact injury risks in team-sports. This study investigated whether player-specific speed zones, reflecting individual fitness characteristics, impact the associations between non-contact injury and acute and chronic HSR loads. Semi-professional soccer players from two clubs (n = 47) were tracked over two seasons using 10 Hz GPS (5552 observations). HSR distances were calculated arbitrarily (≥5.5 m·s^-1), and in an individualised fashion based on the final speed of the 30-15 intermittent fitness test. Cumulative running loads were represented by exponentially weighted moving averages with 7-(acute) and 28-day (chronic) decay parameters. Physiotherapists collected non-contact, lower-limb, time-loss injury data (n = 101). Injury models using session type (training vs matches), coach, as well as arbitrary or individualised running loads were constructed via mixed-effect logistic regression. Session type had the largest effect on injury (training vs match OR = 0.28; 95%CI:0.17-0.44). Variations in individualised or arbitrary acute and chronic HSR loads within the mid-range of the observed data had negligible effects on predicted injury risk. However, the uncertainty of estimated effects at extreme values of acute and chronic HSR loads prevented any conclusive findings. Therefore, the efficacy of using customised speed thresholds in quantifying load for injury risk mitigation purposes remains unclear.

Performance of Professional Soccer Players before and after COVID-19 Infection; Observational Study with an Emphasis on Graduated Return to Play

The impact of the COVID-19 pandemic in sport has been the subject of numerous studies over the past two years. However, knowledge about the direct impact of COVID-19 infection on the performance of athletes is limited, and the importance of studies on this topic is crucial during the current pandemic era. This study aimed to evaluate the changes in the match running performance (MRP) of professional soccer players that occurred as a result of COVID-19 infection after fulfilling all of the prerequisites for a safe return to play (RTP). The participants were 47 professional soccer players from a team which competed in first Croatian division (21.6 years old on average) during the 2020/21 season. The total sample was divided into two subgroups based on the results of a PCR test for COVID-19, where 31 players tested positive (infected) and 16 tested negative. We observed the PCR test results (positive vs. negative PCR), the number of days needed to return to the team, number of days needed to RTP after quarantine and isolation, and MRP (10 variables measured by a global positioning system). The number of days where the infected players were not included in the team ranged from 7 to 51 (Median: 12). Significant pre- to post-COVID differences in MRP for infected players were only found for high-intensity accelerations and high-intensity decelerations (t-test = 2.11 and 2.13, respectively; p < 0.05, moderate effect size differences), with poorer performance in the post-COVID period. Since a decrease of the MRP as a result of COVID-19 infection was only noted in two variables, we can highlight appropriateness of the applied RTP. However, further adaptations and improvements of the RTP are needed with regard to high-intensity activities.

Impact of Preceding Workload on Team Performance in Collegiate Men's Ice Hockey

ABSTRACT

Neeld, KL, Peterson, BJ, Dietz, CC, Cappaert, TA, and Alvar, BA. Impact of preceding workload on team performance in collegiate men's ice hockey. J Strength Cond Res 35(8): 2272-2278, 2021-Although the workload-injury relationship has received ample research attention, the relationship between prior workload and performance in team sport remains poorly understood. The purpose of this study was to determine if preceding workloads influence competition performance in men's ice hockey. On-ice workload data were collected from all players on a NCAA Division I men's ice hockey team for 2 consecutive seasons. Training and match workloads were characterized using 7 variables (player load, skating load, explosive efforts, high force strides, player load·min-1, skating load·min-1, and average stride force·lb-1). Team performance was calculated as the difference between the subject and opposing teams' shots on goal. Nine separate ANCOVAs were performed to assess the effect of workload across quartiles of 5 different time spans (1,3,5,7 and 28 days), and low, typical, and high zones of 4 time ratios (1/28, 3/28, 5/28, and 7/28) days) on team shot differential, accounting for season quarter and rank differential between the subject and opposing team. Alpha was set a priori to 0.05. Of all workload measures included in each analysis, only 7-day high force strides (p < 0.01, eta2 = 0.72), and 7-day player load·min-1 (p < 0.05, eta2 = 0.50) had a significant effect on shot differential. Measures of skating intensity in the week preceding competition have the largest impact on team performance. These results can be used by performance coaches to examine tests of speed, power, strength, and conditioning to identify potential limiting factors to high-intensity skating, design training programs with specific need-based emphases, and make recommendations for weekly management of high-intensity skating loads.

A Cherry, Ripe for Picking: The Relationship Between the Acute-Chronic Workload Ratio and Health Problems

OBJECTIVE

To investigate whether the relationship between the acute-chronic workload ratio (ACWR) and health problems varies when different methodological approaches are used to quantify it.

DESIGN

Prospective cohort study.

METHODS

An online questionnaire was used to collect daily health and training information from 86 elite youth footballers for 105 days. The relationship between players' training load and health was analyzed using a range of different definitions of ACWR and health problems. We used 21-day and 28-day chronic periods, coupled and uncoupled calculations, and the exponentially weighted moving average and rolling average. Acute-chronic workload ratio data were categorized as low, medium, or high, using predefined categories and z scores. We compared medium to high, medium to low, and low to high categories. The outcome was defined in 3 ways: "all health problems," "all injuries," and "new noncontact injuries." We performed random-effects logistic regression analyses of all combinations, for a total of 108 analyses.

RESULTS

We recorded 6250 athlete-days and 196 health problems. Of the 108 analyses performed, 23 (21%) identified a statistically significant (P<.05) association between the ACWR and health problems. A greater proportion of significant associations were identified when using an exponentially weighted moving average (44% of analyses), when comparing low to high categories (33%), and when using the "all health problems" definition (33%).

CONCLUSION

The relationship between the ACWR and health problems was dependent on methodological approach. J Orthop Sports Phys Ther 2021;51(4):162-173. Epub 20 Jan 2021. doi:10.2519/jospt.2021.9893.

Relationships Between Different Internal and External Training Load Variables and Elite International Women's Basketball Performance

PURPOSE

To investigate the relationships between internal and external training load (TL) metrics with elite international women's basketball performance.

METHODS

Sessional ratings of perceived exertion, PlayerLoad™/minute, and training duration were collected from 13 elite international-level female basketball athletes (age 29.0 [3.7] y, stature 186.0 [9.8] cm, body mass 77.9 [11.6] kg) during the 18 weeks prior to the International Basketball Federation Olympic qualifying event for the 2016 Rio Olympic Games. Training stress balance, differential load, and the training efficiency index were calculated with 3 different smoothing methods. These TL metrics and their change in the last 21 days prior to competition were examined for their relationship to competition performance as coach ratings of performance.

RESULTS

For a number of TL variables, there were consistent significant small to moderate correlations with performance and significant small to large differences between successful and unsuccessful performances. However, these differences were only evident for external TL when using exponentially weighted moving averages to calculate TL. The variable that seemed most sensitive to performance was the change in training efficiency index in the last 21 days prior to competition (performance r = .47-.56, P < .001 and difference between successful and unsuccessful performance P < .001, f2 = 0.305-0.431).

CONCLUSIONS

Internal and external TL variables were correlated with performance and distinguished between successful and unsuccessful performances among the same players during international women's basketball games. Manipulating TL in the last 3 weeks prior to competition may be worthwhile for basketball players' performance, especially in internal TL.

Analyzing Activity and Injury: Lessons Learned from the Acute:Chronic Workload Ratio

Injuries occur when an athlete performs a greater amount of activity than what their body can withstand. To maximize the positive effects of training while avoiding injuries, athletes and coaches need to determine safe activity levels. The International Olympic Committee has recommended using the acute:chronic workload ratio (ACWR) to monitor injury risk and has provided thresholds to minimize risk when designing training programs. However, there are several limitations to the ACWR and how it has been analyzed which impact the validity of current recommendations and should discourage its use. This review aims to discuss previously published and novel challenges with the ACWR, and strategies to improve current analytical methods. In the first part of this review, we discuss challenges inherent to the ACWR. We explain why using a ratio to represent changes in activity may not always be appropriate. We also show that using exponentially weighted moving averages to calculate the ACWR results in an initial load problem, and discuss their inapplicability to sports where athletes taper their activity. In the second part, we discuss challenges with how the ACWR has been implemented. We cover problems with discretization, sparse data, bias in injured athletes, unmeasured and time-varying confounding, and application to subsequent injuries. In the third part, conditional on well-conceived study design, we discuss alternative causal-inference based analytical strategies that may avoid major flaws in studies on changes in activity and injury occurrence.

Training Load and Injury: Causal Pathways and Future Directions

Causal pathways between training loads and the mechanisms of tissue damage and athletic injury are poorly understood. Here, the relation between specific training load measures and metrics, and causal pathways of gradual onset and traumatic injury are examined. Currently, a wide variety of internal and external training load measures and metrics exist, with many of these being commonly utilized to evaluate injury risk. These measures and metrics can conceptually be related to athletic injury through the mechanical load-response pathway, the psycho-physiological load-response pathway, or both. However, the contributions of these pathways to injury vary. Importantly, tissue fatigue damage and trauma through the mechanical load-response pathway is poorly understood. Furthermore, considerable challenges in quantifying this pathway exist within applied settings, evidenced by a notable absence of validation between current training load measures and tissue-level mechanical loads. Within this context, the accurate quantification of mechanical loads holds considerable importance for the estimation of tissue damage and the development of more thorough understandings of injury risk. Despite internal load measures of psycho-physiological load speculatively being conceptually linked to athletic injury through training intensity and the effects of psycho-physiological fatigue, these measures are likely too far removed from injury causation to provide meaningful, reliable relationships with injury. Finally, we used a common training load metric as a case study to show how the absence of a sound conceptual rationale and spurious links to causal mechanisms can disclose the weaknesses of candidate measures as tools for altering the likelihood of injuries, aiding the future development of more refined injury risk assessment methods.

What Role Do Chronic Workloads Play in the Acute to Chronic Workload Ratio? Time to Dismiss ACWR and Its Underlying Theory

AIM

The aim of this study was to examine the associations between the injury risk and the acute (AL) to chronic (CL) workload ratio (ACWR) by substituting the original CL with contrived values to assess the role of CL (i.e., the presence and implications of statistical artefacts).

METHODS

Using previously published data, we generated a contrived ACWR by dividing the AL by fixed and randomly generated CLs, and we compared these results to real data. We also reproduced previously reported subgroup analyses, including dichotomising players' data above and below the median CL. Our analyses follow the same, previously published modelling approach.

RESULTS

The analyses with original data showed effects compatible with higher injury risk for ACWR only (odd ratios, OR: 2.45, 95% CI 1.28-4.71). However, we observed similar effects by dividing AL by the "contrived" fixed and randomly generated CLs: OR 1.95 (1.18-3.52) dividing by 1510 (average CL); and OR ranging from 1.16 to 2.07, using random CL 1.53 (mean). Random ACWRs reduced the variance relative to the original AL and further inflated the ORs (mean OR 1.89, from 1.42 to 2.70). ACWR causes artificial reclassification of players compared to AL alone. Finally, neither ACWR nor AL alone confer a meaningful predictive advantage to an intercept-only model, even within the training sample (c-statistic 0.574/0.544 vs. 0.5 in both ACWR/AL and intercept-only models, respectively).

DISCUSSION

ACWR is a rescaling of the explanatory variable (AL, numerator), in turn magnifying its effect estimates and decreasing its variance despite conferring no predictive advantage. Other ratio-related transformations (e.g., reducing the variance of the explanatory variable and unjustified reclassifications) further inflate the OR of AL alone with injury risk. These results also disprove the etiological theory behind this ratio and its components. We suggest ACWR be dismissed as a framework and model, and in line with this, injury frameworks, recommendations, and consensus be updated to reflect the lack of predictive value of and statistical artefacts inherent in ACWR models.

Training Load and Injury Risk in Elite Rugby Union: The Largest Investigation to Date

Training load monitoring has grown in recent years with the acute:chronic workload ratio (ACWR) widely used to aggregate data to inform decision-making on injury risk. Several methods have been described to calculate the ACWR and numerous methodological issues have been raised. Therefore, this study examined the relationship between the ACWR and injury in a sample of 696 players from 13 professional rugby clubs over two seasons for 1718 injuries of all types and a further analysis of 383 soft tissue injuries specifically. Of the 192 comparisons undertaken for both injury groups, 40% (all injury) and 31% (soft tissue injury) were significant. Furthermore, there appeared to be no calculation method that consistently demonstrated a relationship with injury. Some calculation methods supported previous work for a "sweet spot" in injury risk, while a substantial number of methods displayed no such relationship. This study is the largest to date to have investigated the relationship between the ACWR and injury risk and demonstrates that there appears to be no consistent association between the two. This suggests that alternative methods of training load aggregation may provide more useful information, but these should be considered in the wider context of other established risk factors.

Does load management using the acute:chronic workload ratio prevent health problems? A cluster randomised trial of 482 elite youth footballers of both sexes

BACKGROUND

The acute:chronic workload ratio (ACWR) is commonly used to manage training load in sports, particularly to reduce injury risk. However, despite its extensive application as a prevention intervention, the effectiveness of load management using ACWR has never been evaluated in an experimental study.

AIM

To evaluate the effectiveness of a load management intervention designed to reduce the prevalence of health problems among elite youth football players of both sexes.

METHODS

We cluster-randomised 34 elite youth football teams (16 females, 18 males) to an intervention group (18 teams) and a control group (16 teams). Intervention group coaches planned all training based on published ACWR load management principles using a commercially available athlete management system for a complete 10-month season. Control group coaches continued to plan training as normal. The prevalence of health problems was measured monthly in both groups using the Oslo Sports Trauma Research Centre Questionnaire on Health Problems.

RESULTS

The between-group difference in health problem prevalence (primary outcome) was 1.8%-points (-4.1 to 7.7 %-points; p=0.55) with no reduction in the likelihood of reporting a health problem in the intervention group (relative risk 1.01 (95% CI 0.91 to 1.12); p=0.84) compared with the control group.

CONCLUSIONS

We observed no between-group difference, suggesting that this specific load management intervention was not successful in preventing health problems in elite youth footballers.

TRIAL REGISTRATION NUMBER

ISRCTN18177140.

Training Load and Its Role in Injury Prevention, Part 2: Conceptual and Methodologic Pitfalls

In part 2 of this clinical commentary, we highlight the conceptual and methodologic pitfalls evident in current training-load-injury research. These limitations make these studies unsuitable for determining how to use new metrics such as acute workload, chronic workload, and their ratio for reducing injury risk. The main overarching concerns are the lack of a conceptual framework and reference models that do not allow for appropriate interpretation of the results to define a causal structure. The lack of any conceptual framework also gives investigators too many degrees of freedom, which can dramatically increase the risk of false discoveries and confirmation bias by forcing the interpretation of results toward common beliefs and accepted training principles. Specifically, we underline methodologic concerns relating to (1) measure of exposures, (2) pitfalls of using ratios, (3) training-load measures, (4) time windows, (5) discretization and reference category, (6) injury definitions, (7) unclear analyses, (8) sample size and generalizability, (9) missing data, and (10) standards and quality of reporting. Given the pitfalls of previous studies, we need to return to our practices before this research influx began, when practitioners relied on traditional training principles (eg, overload progression) and adjusted training loads based on athletes' responses. Training-load measures cannot tell us whether the variations are increasing or decreasing the injury risk; we recommend that practitioners still rely on their expert knowledge and experience.

Global Positioning System-Derived Workload Metrics and Injury Risk in Team-Based Field Sports: A Systematic Review

OBJECTIVE

To evaluate the current literature regarding the utility of global positioning system (GPS)-derived workload metrics in determining musculoskeletal injury risk in team-based field-sport athletes.

DATA SOURCES

PubMed entries from January 2009 through May 2019 were searched using terms related to GPS, player workload, injury risk, and team-based field sports.

STUDY SELECTION

Only studies that used GPS metrics and had injury as the main outcome variable were included.

DATA EXTRACTION

Total distance, high-speed running, and acute : chronic workload ratios were the most common GPS metrics analyzed, with the most frequent sports being soccer, rugby, and Australian rules football.

DATA SYNTHESIS

Many distinct workload metrics were associated with increased injury risk in individual studies performed in particular sport circumstances; however, the body of evidence was inconclusive as to whether any specific metrics could consistently predict injury risk across multiple team-based field sports.

CONCLUSIONS

Our results were inconclusive in determining if any GPS-derived workload metrics were associated with an increased injury risk. This conclusion is due to a myriad of factors, including differences in injury definitions, workload metrics, and statistical analyses across individual studies.

Acute:Chronic Workload Ratio: Conceptual Issues and Fundamental Pitfalls

The number of studies examining associations between training load and injury has increased exponentially. As a result, many new measures of exposure and training-load-based prognostic factors have been created. The acute:chronic workload ratio (ACWR) is the most popular. However, when recommending the manipulation of a prognostic factor in order to alter the likelihood of an event, one assumes a causal effect. This introduces a series of additional conceptual and methodological considerations that are problematic and should be considered. Because no studies have even tried to estimate causal effects properly, manipulating ACWR in practical settings in order to change injury rates remains a conjecture and an overinterpretation of the available data. Furthermore, there are known issues with the use of ratio data and unrecognized assumptions that negatively affect the ACWR metric for use as a causal prognostic factor. ACWR use in practical settings can lead to inappropriate recommendations, because its causal relation to injury has not been established, it is an inaccurate metric (failing to normalize the numerator by the denominator even when uncoupled), it has a lack of background rationale to support its causal role, it is an ambiguous metric, and it is not consistently and unidirectionally related to injury risk. Conclusion: There is no evidence supporting the use of ACWR in training-load-management systems or for training recommendations aimed at reducing injury risk. The statistical properties of the ratio make the ACWR an inaccurate metric and complicate its interpretation for practical applications. In addition, it adds noise and creates statistical artifacts.

Prior workload has moderate effects on high-intensity match performance in elite-level professional football players when controlling for situational and contextual variables

This investigation examined the effect of prior workload on high-intensity football match performance. Player load variables were recorded using a global positioning system and converted into composite variables: rolling season accumulated load (AL), exponentially weighted moving average acute, chronic and acute:chronic workload ratio (A:C). Match-play high-intensity performance-per-minute: accelerations (ACC), sprints, high-speed running (HSR) and high metabolic load (HMLd) distances; and situational and contextual variables were recorded for all games. Partial least squares modelling, and backward stepwise selection determined the most parsimonious model for each performance variable. Quadratic relationships of small to moderate effect sizes were identified for sprint AL and sprint performance, HSR AL and HSR performance, acute HMLd and HMLd performance, acute sprint load and ACC performance and A:C sprint load and ACC performance. Match performance was typically greatest between the mean and +1SD. High chronic HMLd, and combined acceleration and deceleration (ACC+DEC) load exerted small beneficial effects on HMLd and HSR performance, whereas high acute load exerted trivial to moderate negative effects. High sprint A:C exerted a small beneficial effect on sprint performance and playing position exerted small effects on HSR and HMLd performance. Prior workload has trivial to moderate effects on high-intensity match performance in professional players.

Are internal load measures associated with injuries in male adolescent Gaelic football players?

This study aimed to examine internal loads in male adolescent Gaelic footballers and their association with musculoskeletal injury. Written training diaries were completed by 97 male adolescent Gaelic footballers weekly and injuries, defined as any injury sustained during training or competition causing restricted performance or time lost from play, were assessed by a Certified Athletic Therapist. Daily load was determined for each player (session rating of perceived exertion by session duration) and summed to give weekly load. Univariate and multiple logistic regressions were conducted to determine the association with injury. Twenty-two injuries were recorded with match injuries significantly more common than training injuries. Periodic variations in weekly load and injuries were evident throughout the season. Univariate analysis identified weekly load (OR = 2.75; 95%CI = 1.00-7.59), monotony (OR = 4.17; 95%CI = 1.48-11.72) and absolute change in load (OR = 3.27; 95%CI = 1.15-9.32) greater than the team average were significant injury risk factors. Multiple logistic regression with 2-weekly and 3-weekly cumulative loads, absolute change, monotony, strain, ACWR and age as independent variables identified internal load measures (monotony, strain and absolute change) were associated with injury with high specificity (96.0%) but low sensitivity (25.0%). The findings highlight the need to monitor team and individual loads to avoid sudden week-to-week changes or excessive weekly loads. Open communication between players, parents, coaches and sports medicine clinicians enables effective load monitoring that can reduce injury risk and may subsequently minimise dropout, improve team success and overall sport enjoyment and promote life-long sports participation.

Match and Training Load Exposure and Time-Loss Incidence in Elite Rugby Union Players

Objective

To investigate the impact of match and training load on time-loss incidence in elite, professional Rugby Union players.

Materials and Methods

Eighty-nine Rugby Union players were monitored over two seasons of training and competition. Load was measured for all training sessions and matches using subjective [session ratings of perceived exertion (sRPE) load; RPE × session duration] and objective [global positioning systems (GPS); distance and high-speed running distance] methods and quantified using multiple approaches; absolute match and training load, acute:chronic workload ratio (ACWR), exponentially weighted moving average (EWMA) and cumulative 7, 14, 21, and 28 d sums. Mixed effect models were used to assess the effect of each variable on time-loss incidence.

Results

Of the 474 time-loss incidences that occurred across the two seasons, 50.0% were contact injuries (86.5% occurred during matches and 13.5% during training), 34.8% were non-contact injuries (31.5% occurred during matches and 68.5% during training) and 15.2% were cases of illness. The absolute match and training load variables provided the best explanation of the variance in time-loss incidence occurrence [sRPE load: p < 0.001, Akaike information criterion (AIC) = 2936; distance: p < 0.001, AIC = 3004; high-speed running distance: p < 0.001, AIC = 3025]. The EWMA approach (EWMA sRPE load: p < 0.001, AIC = 2980; EWMA distance: p < 0.001, AIC = 2980; EWMA high-speed running distance: p = 0.002, AIC = 2987) also explained more of the variance in time-loss incidence occurrence than the ACWR approach (ACWR sRPE load: p = 0.091, AIC = 2993; ACWR distance: p = 0.008, AIC = 2990; ACWR high-speed running distance: p = 0.153, AIC = 2994).

Conclusion

Overall, the absolute sRPE load variable best explained the variance in time-loss incidence, followed by absolute distance and absolute high-speed running distance. Whilst the model fit using the EWMA approach was not as good as the absolute load variables, it was better than when the same variables were calculated using the ACWR method. Overall, these findings suggest that the absolute match and training load variables provide the best predictors of time-loss incidence rates, with sRPE load likely to be the optimal variant of those examined here.

Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer)

Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision-making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of 'return to training' and 'return to play' in football. We agreed on 'return to training' and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D.