A comparative study of the effectiveness of an osteopathic primary care sports medicine led intervention on performance in men’s collegiate lacrosse players

Methods

This randomized controlled trial was approved by the New York Institute of Technology (NYIT) institutional board. It was conducted on the NYIT campus. Participant written consent was obtained (by H.Z.) within one week of the commencement of the intervention and stored in a secure location. H.Z. was the principal investigator from the IRB perspective in order to avoid any conflict of interest with the principal author. It was disclosed on the consent that N.C.R. may benefit from the study results, and therefore was not privy to the administering of the study, including the randomization of subjects.

Results

Among 37 total participants at the start of the study (all male; age range, 18–22 years [mean age, 20.2 years]), 23 participants completed the study, whereas 14 were lost to follow-up. Those lost to follow-up chose to leave the study prior to completion of the postseason surveys. There were no adverse effects, but the main reason for 14 being lost to follow-up was that their sport season had ended and they were unable to be reached because they had left campus. The control group included 10 subjects, all males ages 18–22 (mean age, 20.1 years). The experimental group included 13 male subjects (age range, 18–22 years; mean age, 19.9 years).

The overall performance of the team demonstrated improvement, as measured by the number of games won, over the course of the intervention season compared to previous seasons and the following season (Figure 1). The winning percentage was 82%, with 14 games won and three games lost in the intervention season of year 2017. This is noticeably higher than the winning percentage (72–75%) in any other seasons of the three preceding years or the following year when the intervention was not implemented. Body fat composition measurements were reported in Table 1. The change of any body fat composition measurement was not significantly different between the experimental group and the control group.

Figure 1:

Bar graph of the winning vs. losing percentage by year of season.

PHQ-9 and SF-36 scores are reported in Table 2. For both the questionnaire and the survey, the score changes are not significantly different between the experimental group and the control group.

The subject responses to the Osteopathic Primary Care Sports Medicine questionnaire are reported in Table 3. The response changes are not significantly different between the experimental group and the control group.

Discussion

In the current study, the goal was to establish that a comprehensive approach to sports medicine as guided by osteopathic principles was superior to a problem-based approach in that it would improve overall patient health and lead to achievement of patients’ athletic goals. Compliance was a key factor in the intervention, as it was dependent upon monthly meetings between the experimental group and physicians. As a result, there were no statistically significant findings in this study.

Attendance by the student athletes was very poor; less than 50% of the experimental group attended their assigned appointment times. Subjective assessment of compliance with incorporation of the Osteopathic Primary Care Sports Medicine–led intervention principles was also unfavorable in the experimental group. Additionally, throughout the course of the season, support from team leadership appeared to begin to waver as the demands on the athletes increased. For instance, team practices were often scheduled during times designated for appointments. It is also of note that NYIT is a commuter school, so most student athletes do not live on campus, which may have led to difficulty in attending appointments. These athletes also had to contend with a rigorous undergraduate curriculum in addition to their training as a division II lacrosse team. They had little time to prepare healthy meals for themselves, and the resources available in the NYIT cafeteria did not support the dietary principles that the physician advised. Finally, 32% of the study population was lost to follow-up at the end of the study, which further limited the study data.

Therefore, it is clear that multiple factors impacted patient compliance, and we cannot establish whether the lack of statistical significance in this study was due to compliance alone or due to a failure in the intervention. Further research may be warranted to establish the critical factors impacting patient compliance, as well as the factors that impact the establishment of a successful doctor–patient relationship. A way to minimize the dropout rate is to have an app/digital-based tool or telemedicine to communicate with the participants on their smartphones to conduct the sports medicine coaching as well as administer the surveys. It is also reasonable to use digital diaries to monitor adherence to the protocol.

It is important to note that the team winning percentage improved during the time of intervention, as compared to wins and losses over the three previous years (data prior to that were unavailable), and returned to baseline the year after when this intervention was not done. This may indicate that the initial seminar of the Osteopathic Primary Care Sports Medicine–led intervention concepts may have had a positive influence on the team as a whole, although this was not one of our hypotheses. It is noted, however, that this result could be an incidental finding, because team composition year to year was not controlled in this study. Future studies should incorporate athlete performance metrics to better establish how the Osteopathic Primary Care Sports Medicine–led intervention concepts impact team and individual athlete performance as a whole. Furthermore, although randomization of the team was sufficiently performed, it would be useful to control for upperclassmen vs. lowerclassmen, all-conference players vs. non–all-conference players, and other skill level measurements in order to avoid bias in the interpretation of the data.

The osteopathic primary care sports medicine–led intervention proposes that one of the keys to athletic success is to empower the athlete by becoming proficient in understanding and applying the concepts of the nine fundamental roles: team physician, physical therapist, trainer, dietitian, coach, competitor, role model, psychologist, and spiritual leader. The supervising physician plays a critical role because he/she will assess every health aim and injury in the context of the athlete and guide patients to make decisions that support their unique requirements for performance, which includes the establishment of the eight remaining roles [6]. With the support of a supervising physician and with the whole-person approach in place, athletes would be able to achieve the goals they set forth and achieve improved health outcomes as one piece of their overall health picture instead of viewing that aspect independent from the others. In the formation of such a partnership, the physician can lead the athlete in improving their health and performance in their activity of choice. In a previous study that looked at the effect of 87 studies of personalized medicine on patient care, the impact of a physician on psychological and medical treatment efficacy, patient satisfaction, and treatment compliance was demonstrated [7].

Collegiate team physicians, who are osteopathic physicians who practice in the osteopathic philosophy, have resources available for comprehensive care, such as at the Division 1 level. However, not all collegiate sports programs have osteopathic physicians who practice in the osteopathic philosophy or have comprehensive services readily available, suggesting that this model may be a potential solution to improve athletic performance for those who lack the resources.

There is literature on the study of peak performance that exist in disciplines other than the osteopathic team physician. A meta-analysis of 997 studies showed that there is evidence that coach-delivered intervention can have a greater effect on sports performance among psychological and psychosocial interventions [8]. A systemic review of studies involving masters swimmers showed that there was a positive effect on performance when energetics and swim technique were the intervention [9]. A prospective study looking at recovery protocols in baseball players demonstrated a potential for decreased injuries and therefore improved pitching performance [10]. A prospective study of 101 athletes showed that there was a positive association between nutrition knowledge and diet quality that can lead to improved performance [11]. A prospective study of 356 elite youth athletes looked at psychological determinants associated with burnout and correlated them with decreased performance [12]. On the Olympic level, Gould et al. studied performance from a sport psychology perspective and concluded that there are multiple factors that can play a role, such as “psychological, physical, social, and organizational factors.” Specifically, they interviewed eight Olympic teams and found that four teams met/exceeded the expected sport performance measures and four did not [13]. Bytomski published a clinical review studying the impact of nutrition on performance and found that athletic performance would benefit from customized daily and activity-specific nutrition goals [14]. However, we had not identified any studies that approach peak performance from the perspective of an osteopathic team physician through a direct comprehensive intervention. Of note, it is important to understand the different philosophical approaches between osteopathic medicine and allopathic medicine. Although the osteopathic medical doctor utilizes the ‘whole person’ approach, the allopathic medical doctor utilizes a reductionist approach that focuses on symptoms and disease [5]. Further studies are being planned in an attempt to offer an opportunity for the team physician to have a greater impact on the care of the athlete, especially because the effectiveness of a coach in the outcomes of the athlete’s performance is also based on matching the coach’s intention with the needs of the athlete [15].

Conclusion

This study attempted to study a novel approach to increasing performance and health outcomes based upon the osteopathic philosophy that can be integrated into an existing collegiate sports program. With this study being a preliminary report, additional studies will help and are currently being planned to validate this protocol with stricter control of the variables and compliance in the field of performance.