Abstract

Background: Various factors have been studied to determine their ability to predict injury and pain in athletes, including increased mechanical loads, gender, familial history, age, intensity and duration of load and more.

Objective: To determine if pre-season left/right judgement tasks can predict injury and/or pain in children playing basketball.

Methods: Fifty-four middle school students, prior to the basketball season, underwent a battery of tests including gathering demographic information, self-reported pain, fear-avoidance of physical activity, single leg stance test and left/right judgement (laterality) testing for hands and feet. Following the basketball season, a post-season injury and pain report was completed by the students. Analysis was undertaken to see if any pre-season variables correlated to injury, in-season and/or post-season reported pain.

Results: Following the season, 29 students reported an injury, 42 reported in-season pain and 21 reported post-season pain. Injury during the season was correlated with pre-season presence of pain (r = 0.23), hand laterality speed left (r = 0.22), hand laterality speed right (r = 0.21) and hand laterality accuracy on the right (r = 0.27). In-season pain was correlated with right foot laterality accuracy (r = 0.27) and left foot laterality accuracy (r = 0.49). Post-season pain was correlated with pre-season pain (r = 0.36) and closed eyes right single leg stance test (r = 0.24). All correlations ranged from low to moderate.

Conclusion: Pre-season left/right judgement tasks demonstrated a low to moderate correlation to injury and in-season self-reported pain, but not post-season self-reported pain in children playing basketball. Future studies are needed to explore whether these findings can be repeated, elaborated on and if they apply to other sports and age groups.

Keywords: Injury; Middle School Children; Basketball; Pain; Laterality

Abbreviations: ACL: Anterior Cruciate Ligament; FABQ-PA: Fear-Avoidance Beliefs Questionnaire - Physical Activity; S1: Primary Somatosensory Cortex; SLS: Single Leg Stance

Introduction

It is reported that approximately half of all children in the United States participate in organized sports [1-3]. Sports participation offers numerous health benefits to children [1-3]. Not only does it promote physical health, but it’s been shown to lead to lower levels of anxiety and depression, improve social skills including teamwork and communication, and even improved academic performance [1-3]. Additionally, early exposure to sports and physical activity, especially in early adolescence, has shown to be a powerful building block for the future, including establishing adult exercise and health behaviors [4,5]. Unfortunately, with sports participation, injuries often ensue, which may have negative effects including pain, persistent pain, disability, depression, fear-avoidance, catastrophizing and more. Children are not immune to injury and pain, with epidemiological data showing that approximately one in five children experience some form of pain on a regular basis [6].

In sports medicine, attention has shifted from not only treating athletes when they experience an injury and pain, but also towards predictive modeling [7]. Research has been exploring what factors may predispose athletes to injury, which could then be used to develop programs to address these impairments/deficits prior to a season, with the intent to decrease the probability of an injury. A good example is anterior cruciate ligament (ACL) injuries, which often lead to devastating injuries with prolonged recovery. In regards to ACL injuries, it’s been shown that higher ACL injury risk is associated with female athletes with increased dynamic valgus and high abduction loads [7], high-impact rotational landing sports [8], and female youth football players with a familial disposition of ACL injury [9]. In running, previous running-related injury [10], higher body mass index, higher age, sex (male), having no previous running experience, lower running volume [10], and previous stress fractures are associated with higher risk for injury [11]. In baseball, age, height, playing for multiple teams, pitch velocity, and arm fatigue has been tied to increased risk of shoulder and elbow injury during the season [12]. These risk factors are not only confined to physical risk factors, but also psychological and social factors. For example, increased stress levels are predictive of injury in college athletes [10]. On a social level, sleep deprivation and increasing grade in school appear to be associated with injuries in an adolescent athletic population [13]. A large body of research in young athletes shows that specializing in one sport, versus participating in multiple sports, increases risk for overuse injury [14-17].

The human pain experience is complex, and with the advent of brain imaging technology, discoveries in neuroscience suggest that altered body maps, or schemas, in the brain may be linked to the experience of pain in humans [18,19]. The brain contains a network of neurons that represent the physical body and this neural representation corresponds to specific patterns of activity triggered when a particular body part is stimulated [20]. One of the most extensively researched areas involved in this process is the primary somatosensory cortex (S1) [21]. The body schema can therefore be understood as an integrated neural depiction of the body. These representations are continuously adjusted and play a crucial role in both pain perception and treatment strategies [22]. Studies have observed that individuals experiencing pain exhibit different body schema maps compared to those who are pain-free [20-22]. Increasing evidence also suggests that these maps can expand or contract, influencing the brain’s representation of the body, especially in complex pain conditions such as complex regional pain syndrome, phantom limb pain, and chronic low back pain [20-22]. Clinically, these changes in the size and shape of body maps appear to correlate with heightened pain and disability [20- 22]. Although various factors contribute to the development of altered cortical representations in S1, diminished movement and neglect of the painful body part are believed to be key influences [23]. This can lead to a vicious cycle where reduced movement leads to cortical reorganization, further amplifying pain levels.

Most of the research focusing on cortical map changes and pain has centered around complex pain conditions [20-22]. In lieu of the advances in this field of study, studies are also emerging related to cortical body maps and musculoskeletal pain and sports medicine [24,25]. For example, Debenham, et.al., showed that tactile acuity, which is associated with cortical map health, is disrupted in people with Achilles tendinopathy [26], which is a current hot topic in sports medicine. To date, very little work has been done to determine which tests, associated with abnormal cortical body representation, can be predictive of injury and pain. The aim of this study was to determine if left/right judgement tasks (laterality) can predict injury or pain in middle school students during a basketball season.

Methods

Participants

To align with the objectives of this study, written approval was secured from a middle school to carry out the research. The school selected was chosen for convenience, as it provided easy access for the primary investigator, as well as timing to allow for pre- and post-season measurements for the extended basketball league in the region. School administrators were informed of the study’s objectives, provided with an outline, and given examples of the proposed tests and measures. After receiving approval, individual parent written consent was obtained for all kids participating. Participation was entirely voluntary, no identifiable information was gathered by the researchers, and all procedures followed were in accordance with the ethical standards according to the Helsinki Declaration of 1975, as revised in 1983.

Data collection

In a 10-day period, prior to the start of the extended basketball league, students completed a series of surveys and tests:

• Demographic intake form: Students completed, on their own and with the help of teachers, a demographic sheet consisting of grade, gender, self-reported hand and foot dominance, presence of pain at the time of the survey, participation in sports and number of sports they participate in.

• Single leg stance: The Single Leg Stance (SLS) test was used to assess static postural and balance control which provides valuable information about the person’s proprioception, core strength, lower limb stability, and overall balance control [27]. A standard protocol was used where students were tested for SLS (eyes open and closed) for their left and right leg with shoes and socks removed [27,28]. A standardized position was used in which timing began when this position was attained. The standardized position consisted of eyes either open and then closed, hands across the chest and neither the non-weight bearing lower extremity knee nor foot touching any object or contralateral lower extremity. SLS was concluded and the time, in seconds, was recorded upon displacement of the weight-bearing foot, the limb, arms come off the cross-chest position or the time reaches a 60-second capped maximum [27,28]. No data is available for normative data in children, but in adult populations mean eyes open is reported as 29.8 seconds and mean eyes closed as 4.9 seconds [29].

• Fear-avoidance of physical activity: Fear of physical activity was measured using the Fear-Avoidance-Beliefs Questionnaire - Physical Activity (FABQ-PA). The FABQ is a 16-item questionnaire that was designed to quantify fear and avoidance beliefs in individuals with low back pain, and since adopted for musculoskeletal pain. The FABQ has two subscales: 1) a 4-item scale to measure fear avoidance beliefs about physical activity (PA) and 2) a 7-item scale to measure fear-avoidance beliefs about work. Each item is scored from 0 to 6 with possible scores ranging between 0 and 24 and 0 and 42 for physical activity and work subscales, respectively, with higher scores representing an increase in fear-avoidance beliefs. The FABQ has demonstrated acceptable levels of reliability and validity in previous studies [30- 32]. Presence of avoidance behavior is associated with increased risk of prolonged disability and work loss (in adults). It is proposed that FABQ-PA >14 is associated with a higher likelihood prolonged disability [33,34].

• Left-right judgement tasks: To assess the speed and accuracy of identifying left and right body parts (laterality), a laterality application (Recognise™ - noigroup.com) was used for foot and hand images. Kids viewed alternating foot images with no cofounding background or texture (vanilla feet) for 60 seconds. The same protocol was used for hand recognition. The program automatically tracks and reports on the speed and accuracy of the test. Two tests were completed by the kids, and the mean score was used as their final measure [35]. Normative data for accuracy has been reported as > 80% and recognition speed of 2 seconds / image with a standard deviation of 0.5 seconds [36].

Following the 3-month basketball season, an injury report form was distributed to the same students. The injury report gathered self-reported data on prevalence of a sports injury in the past 3 months, prevalence of pain in the past 3 months and experience of pain at the time of the end-of-season. Data packets were coded prior to and following the season to ensure students were matched, to allow for pre- and post-season analysis.

Data analysis

Microsoft Excel™ was used to enter data into spreadsheets and explore summary statistics such as counts, means, ranges, and percentages. Pearson correlation coefficients were calculated to evaluate the strength and direction of linear relationships between pre-season variables and in-season pain, post-season pain and injury. The correlation was applied to pairs of continuous data, producing values ranging from –1 to +1, where coefficients closer to ±1 indicated stronger associations. Results were interpreted based on conventional thresholds (e.g., weak, moderate, or strong correlation) to assess potential patterns or associations relevant to the research objectives.

Results

Participants

Fifty-four middle school students participated in the study (Table 1). Table 2 shows the results from the pre-season testing of the 48 students who participate in sports.

Post-Season Injury and Pain Report

Following the season, 29 students (53.7%) reported they have suffered an injury in the past 3 months. Forty-two students (77.8%) reported a pain experience in the last 3 months, while twenty-one (38.9%) reported pain at the time of completing the post-season survey.

Correlations to Injury During the Season

The various pre-season measurements were tested to determine their correlation to injury during the basketball season. Three factors yielded a positive, but weak correlation to injury including preseason presence of pain (r = 0.23), hand laterality speed left (r = 0.22), hand laterality speed right (r = 0.21) and hand laterality accuracy on the right (r = 0.27) (Table 3).

Correlation to Pain During the Season

The various pre-season measurements were tested to determine their correlation to pain during the basketball season. Right foot laterality accuracy yielded a positive, weak correlation (r = 0.27), whereas left foot laterality accuracy (r = 0.49) showed a moderate correlation to pain experience during the basketball season (Table 3).

Correlation to pain after the season

The various pre-season measurements were tested to determine their correlation to pain at the end of the basketball season. Pain before the start of the season provided a positive, moderate correlation (r = 0.36) to post-season pain, while closed eyes right SLS test (r = 0.24) resulted in a positive, weak correlation to post-season pain (Table 3).

Discussion

The results from this study show that hand and foot left/right judgement task accuracy and speed may have the ability to predict injury and pain during the season, but not after the season, in children playing basketball. Even though the correlations were in general low to moderate, further study is needed to further explore these findings. Of all the tests administered prior to the season, left/right judgement task testing yielded the most positive and highest correlations for injury and in-season pain. It is important to note that the correlations in general were low (n = 3) and moderate (n = 2) but did show some correlation to injury and in-season pain, which warrants additional discussion and research. The sample for this study constituted children between 4th and 8th grade, which correlates to an age group of 9 to 14 years old. This studies’ age group falls within the normative data and values similar to adults, whereas children aged 6 to 9 usually demonstrate lower speed and accuracy scores those older children and adults [37].

In general, the cohort for this study was relatively normal at time of pre-season testing, with three of the four tests yielding normal values (hand accuracy, foot accuracy and foot speed), whereas hand speed was deemed slightly abnormal [37]. To date, only two studies, specifically for children, sports and imagery (i.e., left/right judgement tasks) have been published. Dey, et. al., showed that there was no difference in regards to accuracy or speed in left/right judgement task testing between children who played sport, music, neither, or both [38]. It is important, however, to note that the sample in the Dey, et.al, study included children aged 5 to 17, with the lower age groups representing age groups known to have decreased speed and accuracy in left/right judgment [37,38].

It has been shown that both speed and accuracy associated with left/right judgement tasks are influenced by gender, age and handedness, which may further impact the findings of this study [39,40]. Dhouibi, et. al., however, more recently showed in adolescent athletes that sport and physical education engagement was associated with enhanced motor imagery vividness, with the lower limit for age reported as 13 years-old [41]. The current study, along with the aforementioned two studies [38,41], may indicate that there is a cut-off limit for normative data for children when it comes to left/right judgement tasks, which in turn may impact pain and pain-related behaviors. The findings of this study, albeit low to moderate correlations to injury and in-season pain, warrant further study, especially given the fact that age impacts left/right judgement normative data, especially in children.

The fact that only two studies to date, aside from this study, have explored issues associated with S1 mapping and sports, indicates a significant need for work in this field. The majority of existing brain mapping studies related to sports and physical performance focus on areas of the brain associated with motor planning and execution, exploring these areas in dancers, golfers and judo [42,43]. For example, novice golfers who practice golf increase gray matter in the primary motor cortex and left ventral premotor cortex [43], whereas various studies show alterations in the motor cortex in different dancer-populations [44,45]. Furthermore, it has been shown that high-performance sports are associated with changes in regional brain morphology in areas implicated in motor planning and motor learning [42,46].

These studies, focusing on the motor cortex, are in stark contrast to the minimal content available related to S1 activity. This is especially true for adolescents, which describes the demographic of this study, who have demonstrated increasing mastery of motor actions with age, partly due to maturation of the somatosensory system during adolescence [47]. Somatosensory processing in adolescents has been shown to be less mature than college students, and maturation in adolescent boys and girls are different [48]. The synergy between optimal sensory and motor function is a cornerstone of sports performance. Examples include the ability to manipulate vision to enhance putting accuracy in golf [49] or catching accuracy for wide-receivers [50]. It is recommended that more studies be done exploring changes in S1 related to sports, including the interplay between abnormal S1 mapping, movement, motor control and sports performance.

Additionally, the results from this study showed that there is some correlation between the number of sports played, experiencing pain pre-season and single-leg stance with development of injury, in-season pain and post-season self-reported pain. These findings are in line with previous research. For example, increased playing time and additional load on a younger body has been tied to risk for injury [12], which concur with this study’s finding that number of sports played was associated with a small correlation to in-season pain. In regard to pain, a large body of research has shown that past pain experience is one of the biggest predictors of future pain experiences, including intensity and duration of pain [51-53].

The results from this study concurs with the body of research as it showed that pre-season self-reported pain was correlated with injury and post-season pain. Single leg stance, typically used in elderly populations, is designed as a static balance test to assess fall risk [27,28]. In sports, including basketball, athletes must rely on single leg base of support, and it has been implied that anomalies associated single leg stance may be a contributing factor in sports injuries and resulting pain [27]. In this study, pre-season single leg stance was correlated to post-season self-reported pain. The fact that these three non-laterality measures (pre-season pain, number of sports, and single leg stance) were strengthened by this study’s findings, but left/right judgment tasks were new and novel, strengthening the findings of this study as well as the call to future research.

This study contains various limitations. The first, and most important limitation is that correlation does not mean causation, and further studies are needed to study causation. The second, already mentioned and large limitation, is that the correlations between laterality and injury and pain were low to moderate and interpretation of the results should be seen as that. Third, the study was specific to basketball, and children in a specified age group and demographic. Extrapolating these results to other sports, age groups or demographics should not be done. The post-season data is self-reported data by the children and includes recall.

Conclusion

Pre-season left/right judgement tasks demonstrated a low to moderate correlation to injury and in-season self-reported pain, but not post-season self-reported pain in children playing basketball. Future studies are needed to explore whether these findings can be repeated, elaborated on and if they apply to other sports and age groups.

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