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RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR


DISSERTATION

1 NAME OF THE CANDIDATE Mr. MOHAN.S.


AND ADDRESS I Year M.Sc Nursing,
Padmashree Institute of Nursing
Kengeri, Bangalore-60

2 NAME OF THE INSTITUTE Padmashree Institute of Nursing


Bangalore

3 COURSE OF THE STUDY AND I Year M.Sc Nursing


SUBJECT Child Health Nursing.

19-06- 2009
4 DATE OF ADMISSION
Assessment of effectiveness of
5 TITLE OF THE STUDY structured teaching programme on
knowledge regarding overuse
syndrome among Adolescents at
selected sports associations
Bangalore.

6. BRIEF RESUME OF THE INTENDED WORK


6.1 INTRODUCTION

“We are fortunate to have so much talent on the mound. It is a luxury. We won't burn
kids out or overuse them.”1

Physical activity plays a significant role in the well-being of a child. A well-


designed exercise programme enhances the immediate physical, psychomotor and
intellectual attainments of a child. Long-term health benefits depend on continuation of
the physical activity, thus enhancing well-being and favoring the balanced
development of a child.2

The past decade has seen an explosion in the number of children participating
in team and solo sports. At a young age, sport is for enjoyment and for health and
personal development. This balance changes as a competitive element intervenes.
Subsequently, young athletes train harder and longer and participate in sport
throughout the whole year. As an undesired but inevitable consequence, sports-related
injuries have increased significantly. 2

Athletes are specializing in one sport at younger ages. Year-round training puts
more strain on muscle groups without providing the overused muscles sufficient
recovery time.3

One theory behind the increase in sport specialization at younger ages is the
highly competitive market for college scholarships. Young athletes are pushed harder
to be selected to prestigious club teams with the notion that they will have a better
chance of being seen by college coaches. The push results in harder and longer
training for younger and younger athletes. The price paid is a significant increase in
overuse injuries.3

Overuse syndrome is a condition where a part of the body is injured by


repeatedly overusing or exerting too much strain on that body part.4
An overuse injury is micro traumatic damage to a bone, muscle, or tendon that
has been subjected to repetitive stress without sufficient time to heal or undergo the
natural reparative process. 3

An overuse injury is an injury caused by repetitive stress to muscles, tendons,


and connective tissue that does not have time to heal. The tissue is repeatedly stressed
from too much activity resulting in microtears to the connective tissue. If the tissue
does not have a chance to heal from the initial damage, inflammation can set in. This
can result in localized pain, swelling, and point tenderness to the area. 3

Overuse injuries can be classified into 4 stages:

1. Pain in the affected area after physical activity


2. Pain during the activity, without restricting performance
3. Pain during the activity that restricts performance
4. Chronic, unremitting pain even at rest.3

Strain occur when body part is called on to work harder, stretch farther, impact
more directly or otherwise functions at a greater level then it is prepared for. The
immediate impact may be minute, but when it occurs repeatedly the constant straining
cause damage.3
The term overuse syndrome identifies a large group of conditions that result
from using the body in a repetitious way and causing injury by the amount it is done.3
These conditions are often focused on a joint and usually affect the muscle,
bone, tendon or bursa of the joint. However other anatomical features and areas can be
stressed and their response to that strain can be an injury.3
Some common examples of overuse syndrome are; carpel tunnel syndrome,
Tendonitis, Bursitis, Tennis Elbow, Trigger Finger, Blackberry Thumb, Shin Splints,
Calluses, Bunyan, Etc…3
Overuse injuries can be prevented through educating coaches and
parents as to the early warning signs of injury. Young athletes need to be monitored
closely for any signs of pain in the shoulder and elbow areas. If pain arises, the
athletes need to have an immediate reduction in the amount and intensity of throwing. 3

These types of injuries can also be prevented through providing the athletes
with a proper warm-up (including stretching the muscles that may be at risk for
injury), proper instruction in throwing mechanics, and a slow, gradual, warm-up for
each activity (throwing, pitching). Adding light rotator cuff exercises to the warm-up
can also help by strengthening the small muscles that can be at risk for chronic
injuries.6

Last, the amount that each athlete throws needs to be carefully monitored by
the coaching staff. The number of throws should be age appropriate with care taken to
decrease the number with young athletes and to gradually increase the number of
throws throughout the season. A slow progression of both distance and intensity
should ensure that athletes stay injury free.5

Overuse injuries can be prevented if caught early and managed properly through
the reduction of the activity that caused the initial pain. Athletes with persistent pain
should be referred for medical follow. The following guidelines are suggested to
prevent overtraining/burnout:

1. Keep workouts interesting, with age-appropriate games and training, to keep


practice fun.
2. Take time off from organized or structured sports participation 1 to 2 days per
week to allow the body to rest or participate in other activities.
3. Permit longer scheduled breaks from training and competition every 2 to 3
months while focusing on other activities and cross-training to prevent loss of
skill or level of conditioning. 7

6.2 NEED FOR THE STUDY


Overtraining and burnout among child and adolescent athletes are a growing
problem in the present issue. Although inactivity and obesity are on the rise, the
number of children and adolescents who participate in organized or recreational
athletics has grown considerably over the past 2 decades. It is estimated that 30 to 45
million youth 6 to 18 years of age participate in some form of athletics. Sports
participation is more accessible to all youth, from recreational play and school
activities, to highly organized and competitive traveling teams, to pre-Olympic
training opportunities. 7

The variety of available, organized sporting activities has also grown typical,
such as football, baseball, and soccer, to include, field hockey, rugby, cheerleading,
and dance, each with its own list of sports medicine concerns. This report will assist
the clinician managing young athletes by first defining the medical, psychological, and
developmental concerns of intensive, focused athletic participation. In addition, it will
highlight specific overtraining issues such as participation in endurance events,
weekend athletic tournaments, year-round training on multiple teams, and the
multisport athlete. 7

The incidence of overuse injuries in the young athlete has paralleled the growth
of youth participation in sports. Up to 50% of all injuries seen in pediatric sports
medicine are related to overuse. Because training has become more sport-specific and
nearly continuous, overuse injuries are now common among young athletes recent
data indicat30% to 50% of all pediatric sports injuries are due to overuse . In a study
of children (aged 5 to 17) who presented to a sports injury clinic, 49.5% of 394 sports
injuries were classified as overuse, with boys and girls displaying a similar frequency.
The relative percentage of overuse injuries varies by sport, however. In a 2-year study
of 453 young elite athletes, 60% of swimmers' injuries were due to overuse, compared
to 15% of soccer players' injuries. Athletes who had overuse injuries lost 54% more
time from training and competition than those who had acute injuries.5
Overuse injuries occur when a tissue is injured due to repetitive
submaximal loading. The process starts when repetitive activity fatigues a
specific structure such as tendon or bone. With sufficient recovery, the tissue
adapts to the demand and is able to undergo further loading without injury.
Without adequate recovery, microtrauma develops and stimulates the body's
inflammatory response, causing the release of vasoactive substances,
inflammatory cells, and enzymes that damage local tissue. Cumulative
microtrauma from further repetitive activity ultimately causes clinical injury.
In chronic or recurrent cases, continued loading produces degenerative
changes leading to weakness, loss of flexibility, and chronic pain. Thus, in
overuse injuries the problem is often not acute tissue inflammation, but
chronic degeneration (ie, tendinosis instead of tendinitis). 5

The risks of overuse are more serious in the pediatric/adolescent


athlete for several reasons. The growing bones of the young athlete cannot
handle as much stress as the mature bones of adults. For example, a young
baseball pitcher who has not yet learned proper throwing mechanics (ie,
recruiting the entire kinetic chain—from foot to hand—instead of just the
arm) is at risk of traction apophysitis of the medial elbow. A young gymnast
who performs repetitive hyperextension activities may develop spondylolysis
(ie, a stress fracture of the spine), which is an injury particular to the pediatric
age group. Identifying youth at risk of overuse injuries is the first step to
prevention. Guidelines for parents, coaches, and athletes need to be developed
to provide opportunities for education, injury reduction, and early recognition
of overuse injuries.5

There are physical and physiological differences between children and


adults that may cause children to be more vulnerable to injury. Factors that
contribute to this difference in vulnerability include: children have a larger
surface area to mass ratio, children have larger heads proportionately,

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children may be too small for protective equipment, growing cartilage may be
more vulnerable to stresses and children may not have the complex motor
skills needed for certain sports until after puberty.6

The most commonly injured areas of the body include the ankle and
knee followed by the hand, wrist, elbow, shin and calf, head, neck and
clavicle. Contusions and strains are the most common injuries sustained by
young athletes. In early adolescence, apophysitis or strains at the apophyses
are common. The most common sites are at the knee (Osgood-Schlatter
disease), at the heel (Sever's disease) and at the elbow (Little League Elbow).
Non-traumatic knee pain is one of the most common complaints in the young
athlete. Patellar Femoral Pain Syndrome (PFPS) has a constellation of causes
that include6

Even though growth plate overuse injuries occur frequently in


adolescents, it is equally important for clinicians and parents to realize that
not all overuse injuries are related to the growth plate and will be something
that a child will "grow out of" or play through. Certain growth plate injuries
may continue to be symptomatic over a long period of time. If early diagnosis
is missed, then healing and significant restrictions on athletic participation
can occur. Neglect may also result in long-term problems," said Frush."It's
important for athletes to work with trainers and their sports medicine
specialists to create a rehabilitation program that safely returns them to an
appropriate level of play once healing occurs." 6

Approximately 3–11% of school children are injured per year while


participating in sport. Twice as many boys as girls sustain sports-related
injuries. Some authors report a similar incidence between the genders. Boys,
however, still sustain more severe injuries, possibly because they are more
aggressive. For certain sports, such as horse riding, injuries are four times
more common in females. While the incidence of sports injuries in several

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sports are considered, sports involving contact and jumping have the highest
injury levels, Among girls, soccer had the highest injury rate, followed by
basketball, field hockey, softball and volleyball. Elite athletes, however, have
lower injury rates than the general sporting populations. In general, the
incidence of sports injuries seems to increase with age, approaching the
incidence rate of senior players in the older children. 7

The average young tennis player experiences relatively few


severe injuries. If the young tennis player is participating intensely, however,
exclusively in tennis or in tennis and other sports, injuries occur with
increasing frequency. In addition, intensely active young tennis players can
develop deleterious maladaptations in flexibility and strength in areas subject
to repetitive tensile overload these maladaptations have been shown to
increase with years of tournament play. They impose altered joint
biomechanics, and alter muscular force couples around the joint, may be seen
as risk factors for injury causation, and decrease maximal force production. 7

Time spent in learning how to prevent overuse injuries before they set
in is good training for both parents and coaches. In youth sports, the focus
should be on preventing shoulder and elbow injuries. These injuries include
rotator cuff and biceps tendinitis, medial epicondylitis, and instability of the
medial collateral ligament of the elbow.

1. Encourage athletes to strive to have at least 1 to 2 days off per week


from competitive athletics, sport-specific training, and competitive
practice (scrimmage) to allow them to recover both physically and
psychologically.
2. Advice athletes that the weekly training time, number of repetitions,
or total distance should not increase by more than 10% each week (eg,
increase total running mileage by 2 miles if currently running a total of
20 miles per week).

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3. Encourage the athlete to take at least 2 to 3 months away from a
specific sport during the year.
4. Emphasize that the focus of sports participation should be on fun, skill
acquisition, safety, and sportsmanship.
5. Encourage the athlete to participate on only 1 team during a season. If
the athlete is also a member of a traveling or select team, then that
participation time should be incorporated into the aforementioned
guidelines.
6. If the athlete complains of nonspecific muscle or joint problems,
fatigue, or poor academic performance, be alert for possible burnout.
Questions pertaining to sport motivation may be appropriate.
7. Advocate for the development of a medical advisory board for
weekend athletic tournaments to educate athletes about heat or cold
illness, over participation, associated overuse injuries, and/or burnout.
8. Encourage the development of educational opportunities for athletes,
parents, and coaches to provide information about appropriate
nutrition and fluids, sport safety, and the avoidance of overtraining to
achieve optimal performance and good health. 6

An increasing number of children take part in organized sporting


activities, undergoing intensive training and high level competition from an
early age. Although intensive training in children may foster health benefits,
many are injured as a result of training, often quite seriously. This paper
reviews some of the areas of research dealing with intensively trained young
athletes, and focuses on physical, cardiovascular and muscular effects, sports
injuries and psychological effects of intensive training. It is concluded that
measures should be taken to modify present training and competition schemes
to avoid the deleterious effects of intensive physical activity on these
children. 7

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In light of above facts with the personal experience of the investigator
working as staff in caring adolescents have encountered many injuries
specially sports persons complaints of various injuries. So this has created
interest in investigator to provide a structured teaching programme on
overuse syndrome among Adolescents

6.3 STATEMENT OF THE PROBLEM

A study to assess the effectiveness of structured teaching programme on


knowledge regarding overuse syndrome among Adolescents at selected sports
associations, Bangalore.

6.4 OBJECTIVES

1 .To assess the pretest knowledge regarding Overuse syndrome among


Adolescents.
2. To assess the post test knowledge regarding Overuse syndrome among
Adolescents.
3. To evaluate the effectiveness of structured teaching programme on
Overuse syndrome among Adolescents.
4. To associate post test knowledge regarding Overuse syndrome among
Adolescents with their selected demographic variables.

6.5 OPERATIONAL DEFINITIONS

1. Knowledge:
It refers to level of understanding regarding overuse syndrome among
Adolescents
2. Effectiveness:
It refers to the improvement in knowledge on Overuse syndrome among
Adolescents.

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3. Structured teaching programme:
It refers to systematically organized teaching strategy for duration of 45 mins
to one hour on Overuse syndrome, its definition, causes, injuries and
prevention among Adolescents, by verbal interaction with the use of flash
cards.

4. Overuse syndrome:
It is a condition where a part of the body is injured by repeatedly overusing or
exerting too much strain on that body part.

5. Adolescents:
Adolescents are undergoing training in sports association of age group
between thirteen to nineteen years.
.
ASSUMPTIONS

1. Adolescents may have inadequate knowledge regarding Overuse syndrome

2. Structured teaching programme will improve the knowledge regarding


Overuse syndrome among Adolescents.

3. Adolescent’s knowledge may vary with their selected demographic


variables.

6.7 RESEARCH HYPOTHESES

H : There is a significant difference between mean pre test and post test
1

knowledge regarding Overuse syndrome among Adolescents.

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H : There is a significant association between the knowledge of the
2

Adolescents with their selected demographic variable.

6.8 REVIEW OF LITERATURE

ORTON Research Institute, ORTON Foundation, Helsinki, Finland


conducted Twelve-month retrospective study on Gender differences in sport
injury risk and types of injuries among cross-country skiers, swimmers, long-
distance runners and soccer players. This twelve months survey compared
injury risk and injury types by genders (312 females, 262 males) .More male
than female runners reported at least one Overuse injury After adjustment for
sport event males were at increased risk for posterior thigh Overuse injuries
compared to females while females were at increased risk for overuse injuries
in the ankle compared to males After adjustment for exposure time
(injuries/1000 exposure hours) significance of the difference between the
sexes in Overuse injury to the ankle persisted. they conclude there are some
gender differences in sport- injuries.8

A study done on to determine the relationship between lower extremity


alignment and MTSS amongst non-professional athletes in a prospective
Study, sixty six subjects were evaluated. Runners were followed for 17 weeks
to determine occurrence of MTSS .The overall injury rate for MTSS was
19.7%. The MTSS injury rate in girls (22%) was not significantly different
from the rate in boys (14.3%). Most MTSS injuries were induced after 60
hours of exercise, which did not differ between boys and girls. There was a
significant difference in right and left navicular drop (ND) in athletes with
MTSS.9

Musculoskeletal Research Centre and School of Physiotherapy,


La Trobe University, Victoria, Australia conducted a study on volume of
physical activity and injury occurrence in young basketball players. Detailed
physical activity and injury data were prospectively collected in 46 school-

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level basketball players aged 14 to 18 years. Results showed that athletes who
specifically sustained overuse injuries (p = 0.01) participated in a greater
amount of basketball refereeing than uninjured athletes. 10

A study was done to examine whether bowling workload is a risk


factor for overuse injury to Australian junior cricket fast bowlers and to
evaluate the appropriateness of current bowling workload guidelines.
Bowling workload prior to the first injury (for those bowlers who were
injured) was compared to workload across the whole season for uninjured
bowlers. Results: Eleven (25%) bowlers reported an overuse-type injury, with
seven of these sustaining a back injury. Increased risk of injury for those who
bowled an average of ≥2.5 days per week or ≥50 deliveries per day .This
study has identified high bowling workload as a risk factor for overuse injury
to junior fast bowlers. 11

Department of Trauma and Orthopaedic Surgery, Keele University


School of Medicine, UK, conducted a study on Sports injuries in children.
Sports injuries in children affect both growing bone and soft tissues, and can
result in damage of growth mechanisms with subsequent lifelong, growth
disturbance. During growth, there are significant changes in the
biomechanical properties of bone. In young athletes, as bone stiffness
increases and resistance to impact diminishes, sudden overload may cause
bones to bow or buckle. Fractures that are initially united with some
deformity can completely remodel, and the bone may appear totally normal in
later life.12

A study was done on Swimming overuse injuries. Swimming injuries


are unique in that they involve upper limb overuse more than lower limbs and
that swimming is performed in a non-weight-bearing fluid setting. Identifying
the mechanism of injury and prescribing appropriate management is not easy
unless one has a thorough understanding of proper technique of the four
competitive strokes. Understanding the psychology of swimming athletes will

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improve outcome and compliance. The goals of this article are to familiarize
the reader with the diagnosis and management of swimming injuries and to
improve the physician's effectiveness in dealing with swimmers through a
thorough understanding of technique and psychology. 13

The Research Station of Sports Medicine, Tampere, Finland


Conducted a 30-month prospective follow-up study of children's overuse
injuries at an outpatient sports clinic was carried out to determine the number,
profile, and specific features of these injuries compared with those of young
adults. During this period 74 athletically active boys ( 15 years), 83 girls, 255
men (21-30 years), and 77 women visited the station because of an overuse
sports injury of the musculoskeletal system. In girls and women, the lower
back (13%) was significantly more frequently affected than in boys and men
(6%).Thirty two percent of all boys' overuse problems were classified as
exercise-induced growth disorders and osteochondritic pains (apophysitides,
etc.), but in girls only 13% had a similar basis. 14

  A study was done to determine whether there are significant


differences in the causes of back pain in young athletes compared with the
general adult population and to review the diagnosis and assessment of young
athletic adolescent patients who present with this complaint. Forty-seven
percent of the 100 adolescents were ultimately shown to have a spondylolysis
stress fracture of the pars interarticularis. By contrast, 5% of adult subjects
were found to have spondylolysis associated with low back pain. Similarly,
discogenic back pain was the final diagnosis in 48 of the 100 subjects in the
adult group, while 11 of the 100 in the adolescent group had back pain
attributable to disc abnormalities. 15

An 8-Season Prospective Study done on Injuries in Young Elite Female


Soccer Players, Injuries sustained by players between 15 and 19 years of age,
during 8 seasons, Altogether 619 injuries were documented for 110 players
(92.4%). Of these injuries, 64.6% were sustained during training and

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matches, respectively. The risk of injury was greater in the youngest (under
age 15) group compared with the oldest (under 19) group and 83 (13.4%)
were overuse injuries. There were 51.9% minor injuries, 35.7% moderate
injuries, and 12.4% major injuries.16

A study was done on Overuse Injuries in Female Athletes. The last


three decades have witnessed a tremendous increase in female sports
participation at all levels. However, increased sports participation of female
athletes has also increased the incidence of sport-related injuries, which can
be either acute trauma or overuse injuries. This study reviews the most
frequent overuse injuries in female athletes in the context of anatomical,
physiological, and psychological differences between genders. Although
injuries tend to be sport-related rather than gender-related, it has been noted
that certain conditions, such as patellofemoral pain syndrome, stress
fractures, or lateral epicondylitis are especially prevalent in female athletes . 17

A Prospective Study was done to evaluate prospectively leg length


discrepancy, hip flexor tightness, and lower extremity acquired laxity or
overuse as predictive factors for low back pain in college athletes. Two-
hundred fifty-seven college athletes representing nine varsity sports were
screened during a preseason sports physical examination. Results were
Twenty-four athletes (9.3%) received treatment for low back pain. Thirteen of
87 women (15%) compared with 11 of 170 men (6%) required treatment for
low back pain (P = 0.048). Of 57 athletes with lower extremity acquired
laxity or overuse, low back pain developed in 14 (P < 0.001), conclude that
Athletes with lower extremity acquired ligamentous laxity or overuse may be
at risk for the development of noncontact low back pain during athletic
competition.18

A study was done on running Overuse injuries. It is the primary culprit


in most running injuries, with biomechanical factors playing a much smaller
role. Non-musculoskeletal events that may be related to a musculoskeletal

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injury such as exercise-associated amenorrhea and chronic fatigue or
depression are reviewed. That running may promulgate osteoarthritis is still
controversial. However, the preponderance of data gives insufficient credence
to the idea of osteoarthritis as a complication of long-distance running. With
regard to treatment, nonsteroidal anti-inflammatory drugs appear to play little
or no effective role in the management of running injuries19

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected, from the Adolescents at selected sports


associations Bangalore.

7.2 METHODS OF COLLECTION OF DATA


i. Research design
Quasi-Experimental - one group pretest posttest design

ii. Research variables


Dependent variables:
Level of knowledge regarding overuse syndrome among Adolescents
.
Independent variables:
Structured teaching programme on knowledge regarding overuse syndrome
among Adolescents

iii. Setting
The study will be conducted at selected sports associations Bangalore.

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iv. Population
All the Adolescents of age group between thirteen to eighteen years in
selected sports associations Bangalore.

v. Sample
Adolescents who fulfill inclusion criteria and the sample size will be 60.

vi. Criteria for sample selection


Inclusion criteria:
The study includes:
1. Adolescents are undergoing training in sports association
2. Adolescents of age group between thirteen to nineteen years.
3. Adolescents who are available at the time of data collection.

Exclusion criteria:
The study will exclude:

1. Adolescents, who cannot understand Kannada or English language.


2. Adolescents who are not willing to participate

vii. Sampling technique


Non- probability convenient sampling technique.

viii. Tool for data collection


The tool consists of two sections:

Section A:
Demographic variable such as age, sex, education, type of sports,
religion, occupation of parents, duration of practice, food pattern

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Section B:
Structured questionnaire is used to assess the knowledge on Adolescents
regarding Overuse syndrome.

ix. Method of data collection.


After obtaining the permission from the concerned authorities and
informed consent from the samples the investigator will collect the data in
following three phases.

Phases-One - Pre test will be given to assess the existing knowledge on


Adolescents regarding Overuse syndrome with the help of structured
questionnaire.

Phases-Two - On the same day structured teaching programme will be given


to Adolescents on Overuse syndrome by using flash card for 45mt -1 hr
duration.

Phases-Three - Same questionnaire will be administered to Adolescents on


Overuse syndrome, after 7 days.
Duration of the data collection is 4 to 6 weeks.

x. Plan for data analysis


The data collected will be analyzed by means of descriptive statistics and
inferential statistics.

Descriptive statistics:
Frequency and percentage distribution of demographic variables will be
analyzed. Mean, and standard deviation will be used to assess the level of
knowledge of Adolescents regarding Overuse syndrome.

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Inferential statistics:
Paired-'t' test will be used to compare the pretest and posttest knowledge
regarding Overuse syndrome among Adolescents; chi-square test will be used
to associate posttest knowledge on Overuse syndrome of Adolescents with
selected demographic variable.

xi. Projected outcome

Structured teaching will improve the knowledge of Adolescents


regarding Overuse syndrome. This will enable the Adolescents to improve
their self-help skills in their activities of daily living.

7.3 Does the study require any investigation or interventions to be


conduct on patients or other human or animals?

Yes, structured teaching programme will be administered for Adolescents on


Overuse syndrome in selected sports associations, Bangalore.
.
7.4 Has ethical clearance been obtained from your institution?

Yes, permission will be obtained from concerned authority and informed


consent will be obtained from samples.

List of references:

1. Rosaline Dickson quotes Available from: URL: .http//www.thinkexist.com

2. Hockensberry, Wilson, Wong’s nursing care of infants and children; child


with musculoskeletal or articular dysfunction.eigth edition, 1771-1772.

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3. Terry, Zeigler Preventing Overuse Injuries in Youth Sports Mar 28, 2009
Available from: URL: http://how-to play.com.

4. Dorothy R Marlow, Barbara, A Redding Text book of pediatric nursing;


behavioral characteristics of adolescents. Philadelphia: Elsevier, 2005.733-34

5. John P. DiFiori, Overuse Injuries in Children and Adolescents. The


physician and sports medicine 1999 January ; 27 (1).

6. Hockberry, Wilson, winkelsteina, kelin, Wong’s. Sports injuries, 2005


Philadelphia: Elsevier,. 546

7. Joel S. Brenner, Overuse Injuries, Overtraining, and Burnout in Child and


Adolescent Athletes; journal of Pediatrics June 2007; 119 (6), 1242-1245

8. Leena Ristolainen, Ari Heinonen, Benjamin Waller, Urho M. Kujala and


Jyrki A. Kettunen, Gender differences in sport injury risk and types of
injuries: Journal of sports Science and Medicine 2009, 443-451 available
from: URL http://www.jssm.org.

9.Jenny Gianoudis, Kate E. Webster and Jill Cook, volume of physical


activity and injury occurrence in young basketball players, Journal of Sports
Science and Medicine 01 March 2008, 139 - 143 .

10. Dennis , Finch ,Farhort  , James trefor, stretch r. Is bowling workload a


risk factor for injury to Australian junior cricket fast bowlers? 2005; British
journal of sports medicine, vol 39, 843-846 

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11. Chezhiyan Shanmugam and Nicola Maffulli, Sports injuries in
children
.Department of Trauma and Orthopaedic Surgery, Keele University School
of Medicine

12 .Jones, J H (JH). Swimming overuse injuries; Journal of Physical medicine


and rehabilitation clinics; Feb 2009; 10 (1) 77-94.

13. Pekka Kannus, Seppo Niittymäki, Athletic Overuse Injuries in Children


the Research Station of Sports Medicine, Tampere, Finland.

14. Lyle J. Micheli, Robert Wood. Back Pain in Young Athletes Significant
Differences From Adults in Causes and Patterns, Arch Pediatric Adolescence
Med. 1995;149(1):15-18.

15. Omey, Monica l.; Micheli, Lyle J. Foot and ankle problems in the young
athlete, Clinical Supplement: Foot and Ankle; Medicine & Science in Sports
& Exercise: July 2009; 31 (7) S470-S486

16.Franck Le Gall, MD, Carling, and Thomas Reilly, PhD Institute of


National Football United Kingdom Injuries in Young Elite Female Soccer
Players, An 8-Season Prospective Study.

17.Alan Ivković, Miljenko Franić, Ivan Bojanić, and Marko Pećina , Overuse
Injuries in Female Athletes; 2007 December; Medical journal,767–778.

18. Nadler, Scott F, Karen D, Galski, Thomas, Feinberg, Joseph H. Low Back
Pain in College Athletes Health Services Research; April 1998 ; 23(7) 828-
833.

19. Paty, John G. Jr. Sports-related injuries, and related conditions: Running
injuries, Lippincott-Raven Publishers.

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