SSI Updates

Division II members support health and safety proposals

The Division II membership passed legislation impacting health and safety issues, football conditioning workouts, conference challenge basketball events and championships selections during Saturday’s business session at the NCAA Convention.

Division III members approve sport safety package

Division III passed three elements of the sport safety package package recommended by CSMAS by a wide margin during Saturday’s business session at the NCAA Convention.

Do Female Athletes Concuss Differently than Males?

By: Brian Hainline, MD

Do Females Concuss Differently?

Do females concuss differently than males?

It’s a compelling question among concussion researchers. Despite the intrigue of this question, there is little media attention to this matter. The tendency of the media is to focus on football. The advantage of this column is that I can choose the topics that need to be communicated to a broader audience. Therefore, I am devoting this column to explore concussions in female athletes.

A female’s brain is different than a male’s brain. This is a statement of fact, not judgment. One difference in particular has to do with a female’s susceptibility to migraine between puberty and menopause. During the child-bearing ages, females undergo considerable hormonal fluctuation on a monthly basis in preparation for possible pregnancy. Estradiol in particular reaches peak levels as the uterus becomes prepared for possible embryo implantation, and then drops precipitously if no implantation takes place. Estradiol fluctuation is one of the primary culprits in driving migraine. Before puberty and after menopause, males and females suffer with migraine equally. During child-bearing ages, females are about four times more likely to suffer with migraine. Estradiol interacts specifically with the trigeminal vascular complex, which is an area of the brain that controls migraine pathophysiology.

Why do we care about migraine when discussing concussion in females? Because migraine and concussion share similar pathophysiological expressions. During a migraine aura (often experienced as visual hallucinations), there is an excitatory electrical phenomenon in the brain that is followed by an inhibitory electrical phenomenon. This inhibitory electrical phenomenon is known as ‘spreading depression.’ Spreading depression refers to waves of depressed electrical activity in the brain and has nothing to do with emotions, per se. Think of a pebble that is dropped in a still lake. There are observable waves that emanate from the epicenter of the dropped pebble, and these waves are conceptually similar to the spreading depression waves that occur during a migraine aura. As a result of the progressive inhibitory electrical spread, there is associated neurological dysfunction, ranging from visual loss to difficulty speaking to confusion to vertigo to loss of consciousness.

Scientists have also described spreading depression as an acute manifestation of concussion. Following an impact to the brain sufficient to cause a concussion, there are multiple areas of the brain that may develop spreading depression waves, and this may be an important contributing factor to concussion symptomatology. This also explains why concussion symptoms can worsen for hours following the inciting event. For female athletes during their child bearing years, there is a statistically increased likelihood that a female with migraine susceptibility will become concussed, and such females have a lower threshold to developing secondary spreading depression. In other words, females with migraine susceptibility are more vulnerable to developing worsened symptoms relative to their non-migraine counterpart. At present, the spreading depression hypothesis needs further scientific study; however, it is an intriguing explanation of male-female differences. Spreading depression may help to explain studies that demonstrate the following:

  • Female concussed athletes report more concussion symptoms than their male counterparts, including poor concentration, lightheadedness, increased fatigue, headache, and visual hallucinations such as seeing stars.
  • Female concussed athletes suffer with greater cognitive decline and slowed reaction time relative to males.
  • College female concussed athletes perform more poorly on BESS (Balance Error Scoring System) following concussion relative to males.

In addition to suffering with more concussion symptomatology, females have a higher rate of concussion compared to males when playing the following sports:

  • Soccer (2.1 x greater risk)
  • Softball versus baseball (up to 3.2 x greater risk)
  • Basketball (up to 1.7 x greater risk)

In self-report data that we will explore further in a future column, college female ice hockey players have the highest odds ratio of developing concussion, even when considering football, a male-only event. Thus, female athletes seem uniquely predisposed to suffering with more concussion and worsened concussion symptomatology relative to males. What is startling is that even in lacrosse, female athletes seem to suffer concussion at a similar incidence to males, but female lacrosse is not a contact sport, whereas male lacrosse is a contact sport.

Studies have also demonstrated that females have more injuries due to player-surface contact and player-equipment contact compared to males (males have more injuries from player-player contact compared to females). Females also may have a higher proportion of recurrent concussions compared to males. There may be factors beyond brain physiology that help explain these differences. One aspect of concussion is the biomechanical readiness of protecting the head from sudden acceleration-deceleration and rotational forces. From this framework, females may be at a disadvantage because they have less neck strength than males. This can translate into less ability to counteract mechanical forces that can cause head and neck acceleration-deceleration and rotation. Consider the following statistically significant difference in females compared to males when measuring head-neck strength components and concomitant acceleration forces:

  • Females have 25 percent less head-neck segment mass than males.
  • Females have 5 percent less head-neck segment length than males.
  • Females have 12 percent less neck girth than males.
  • Females have 50 percent less isometric neck flexor strength than males.
  • Females have 53 percent less isometric neck extensor strength than males.
  • Females have up to 44 percent greater head acceleration than males following contact, and have 10 percent greater head accelerations than males during non-contact.

We need to explore female-male concussion differences in more detail. Meanwhile, we all need to spread the word: yes, female athletes also suffer with concussion, and they may be uniquely predisposed to this neurological event.


  1. Yoshino A et al: Dynamic changes in local cerebral glucose utilization following cerebral concussion in rats: evidence of a hyper- and subsequent hypometabolic state. Brain Research 1991; 1:106-119.
  2. Hainline B: Migraine and other headache conditions. In Hainline B, Devinsky O (eds): Neurological Complications of Pregnancy, Second Edition, Philadelphia, Lippincott Williams & Wilkins, 2002, pp25-40.
  3. Lincoln AE et al: Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med 2011; 39:958-963.
  4. Marar M et al: Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med 2012; 40:747-755.
  5. Broshek DK et al: Sex differences in outcome following sports-related concussion. J Neurosurg 2012; 116:856-863.
  6. Covassin T et al: The role of age and sex in symptoms, neurocognitive performance, and postural stability in athletes after concussion. Am J Sports Med 2012; 40:1303-1312.
  7. Colvin AC et al: The role of concussion history and gender in recovery from soccer-related concussion. Am J Sports Med 2009; 37:1699-1704.
  8. Tierney RT et al: Sex differences in head acceleration during heading while wearing soccer headgear. J Athl Train 2008; 43:578-584.

NCAA Doping, Drug Education and Drug Testing Task Force

The NCAA Sport Science Institute convened a Doping, Drug Education and Drug Testing Task Force in July 2013 (for a list of task force members see NCAA Doping Drug Testing and Drug Education Task Force Members).  The purpose of the task force was to provide a broad overview of doping, drug education and drug testing and to address collegiate-specific concerns.  A series of three articles published via the Sport Science Institute Newsletter will summarize key task force findings.  The first article will cover the historical background of doping and drug testing in sport, and include an overview of performance-enhancing drugs.  A second article will review alcohol and recreational drug abuse.  The final article will review the drug testing process and future considerations.

Historical Background

Doping refers to the use of performance-enhancing drugs, and has always been a part of sport; whenever there is a combination of competition and rules of engagement, there are competitors who seek an unfair competitive advantage, and this includes doping.  In the 3rd century BC, Greeks ingested mushrooms to improve athletic performance.  In the famed Circus Maximus, gladiators used stimulants to fight despite fatigue and injury.  Modern day drug testing was first introduced in the 1968 Olympic Games.  The World Anti-Doping Agency (WADA) was established in 1999 to promote, coordinate and monitor the fight against doping in sports. 

The NCAA has been part of the modern day drug testing movement.  Due to concern about the possibility of increasing drug abuse among college student-athletes, the NCAA established the Drug Education Committee in August 1970.  At the 1971 Annual Convention, NCAA members passed a resolution condemning the use of nontherapeutic drugs in college sport, stating that such use was a violation of the NCAA’s principles of ethical conduct.  In 1984, NCAA Convention delegates approved a resolution from the Pacific-10 Conference directing the NCAA Executive Committee to develop a testing program for NCAA Championships.  The first postseason drug testing program for Divisions I, II and III was approved in 1986. This included testing for marijuana and allowed for medical exceptions for therapeutic drugs.  In 1988, the Committee on Competitive Safeguards and Medical Aspects of Sports (CSMAS) assumed responsibility for NCAA drug education and testing programs.  Year-round drug testing was introduced in 1989, and initially only included Division I football.  With the intent of providing independent administration and transparency, the NCAA transferred the administration of drug testing programs to The National Center for Drug Free Sport, Inc. (Drug Free Sport) in 1999.  Since then, Drug Free Sport has administered drug testing for all NCAA sports, with year-round (including summer) and championship drug testing.

Although it might seem self-evident to have a drug testing program in sport, we might take a step back and ask: “What’s wrong with drug use in sport?”  Once we ask this question, we delve into practical ethics; good ethics begin with good facts, and must be within the conceptual framework of values and meaning in sport.  With this in mind, the U.S. Anti-Doping Agency (USADA) conducted a survey across a large cross-section of America.    As noted in Table 1, the top five values reinforced through sport are: honesty; fair play; respect for others; doing your best; and teamwork.

Table 1. Importance of Values to Reinforce Through Sport

Table 2 demonstrates that the top five perceptions of values most reinforced through sport are: competitiveness; winning; hard work; teamwork; and doing your best.


Table 2. Perceptions of Values Most Reinforced Through Sport

Interestingly, “fun” is the primary motivator for becoming involved in sport, for both the general population and for national governing body (NGB) sport participants (See Table 3).


Table 3. Top Motivators for Becoming Involved in Sport

And perhaps most importantly, the USADA survey found that the use of performance-enhancing substances is the most serious ethical issue facing sport today (See Table 4). 

Table 4. Values & Ethics: Seriousness of Issues Facing Sport Today


How do we bring this back to doping in sport? Consider the many reasons we play sport:

·         To learn values such as honesty, hard work, fair play, respect for others, and doing your best.

·         To have fun and have companionship.

·         For the drive of doing something well and mastering a skill.

·         To develop character.

·         To have glimpses of excellence in the harmony of the mind and body.


We must always balance values and ethics in sport with the fact that sport is also inherently and relentlessly competitive.  At the margins of competition, some athletes, coaches or parents will do anything to gain a competitive advantage.  With regard to doping in sport, there exists the possibility that a small advantage from performance-enhancing drug use may be greater than a slightly smaller advantage from talent and hard work alone.  This means that when performance-enhancing drugs make a difference ­– and they can – clean athletes must choose among a few possibilities:

·         Compete at a possible disadvantage.

·         Take your talents elsewhere.

·         Join in the cheating.


The point of doping control is to provide clean athletes a fair contest.  Without doping control, there is the possibility that performance-enhancing drug use will not be contained, with never-ending pressure to use more drugs, higher dosages, and bizarre and dangerous combinations.  This leads to an inevitable contagion to our youth.  Just as we make decisions about the rules and equipment of sport to preserve a sport’s meaning, we also make decisions to deter doping in sport.  Rules changes, equipment recommendations and doping control share the same common intent:

·         Promotion of fairness.

·         Prevention of harm.

·         Preservation of meaning.


In addition to doping control having an ethics-based foundation, we might also consider that doping control in sport is a public health issue.  Because of the relentlessly competitive structure of sport, without doping control there could exist an uncontrolled, massive pharmaceutical experiment that would indeed be a public health risk.  If some athletes are willing to resort to anything to win at all costs, then the intrinsic value of sport is undermined, with potential serious health and social costs.  Doping control allows athletes to compete while celebrating excellence in mind, body and spirit.  For doping control to be truly successful, we must enlist all of our athletes in the cause. 


Performance-Enhancing Drugs

Performance-enhancing drugs (PEDs) are drugs that allow an athlete to attain an otherwise unreachable level of performance.  PEDs work through some combination of:

·         Muscle or skeletal growth.

·         Increased work potential, either through hastened recovery or diminishing fatigue.

·         Increased focus or aggression.

PEDs also include drugs that may mask the detection of other PEDs.


PEDs include the following:

·         Anabolic agents: Drugs that promote the storage of protein and the growth of tissue.  Examples include:

o   Testosterone and anabolic-androgenic steroids: Anabolic-androgenic steroids, often called anabolic steroids, mimic the effects of testosterone..  Testosterone is a hormone that is produced in the body of males and females, although in much higher levels for males.  Testosterone is responsible for the development of primary male sexual characteristics in utero, and a surge in testosterone production during puberty leads to the development of secondary male characteristics.   Within this class of drugs, one cannot separate the anabolic effects (muscle building and improved recovery) from the androgenic effects (increased secondary male characteristics).  From a doping perspective, athletes ingest or inject testosterone and related anabolic steroids for:  

·         Increased muscle growth and muscle strength, coupled with weight gain.

·         Hastened recovery.

·         Increased aggressiveness.


o   Human Growth Hormone (hGH): Human growth hormone is produced within the body, and is responsible for proper organ growth and development.  Physiological effects of hGH include the incorporation of amino acids into protein muscle; the stimulation of glucose uptake in muscle; antilipolytic effects in adipose tissue (e.g., the breakdown of fat).  Like testosterone and other anabolic steroids, hGH can be delivered as a performance-enhancing drug by way of an injection.  When taken as an exogenous substance for doping, hGH may lead to:

·         A synergistic effect with testosterone, (e.g., an increase in the anabolic effects of testosterone).

·         Breakdown of excessive fat and weight loss.


o   Human Chorionic Gonadotropin (hCG): Human chorionic gonadotropin is produced within the body and is primarily responsible for stimulating the body’s normal production of testosterone.  When delivered by way of an injection for doping, hCG may lead to excessive testosterone production, thereby leading to similar effects of other anabolic steroids.  Some athletes will also use hCG to prevent testicular atrophy, which can develop with prolonged use of anabolic steroids.


o   Clenbuterol: Although banned in the United States, clenbuterol is a drug that is used in some countries to treat asthma and related conditions..  Like other inhaled asthma drugs, clenbuterol is a bronchodilator, meaning that the airways become less constricted.  Clenbuterol also has a combination of anabolic properties (improves muscle mass) and fat-burning properties (lean muscle), and is therefore considered an anabolic agent.  It is noteworthy that clenbuterol is often given to animals in an attempt to produce lean meat.  Clenbuterol is used as a doping agent because of its potential anabolic properties.


o   Selective Androgen Receptor Modulators (SARMs): SARMs are drugs that bind to receptors in the body with the intent of increasing anabolic potential (e.g., muscle building and hastened recovery) while avoiding androgenic effects (e.g., the secondary male characteristic effects of testosterone and other anabolic-androgenic steroids).  SARMs are reputedly becoming popular as doping agents within the athletic community because of their more selective anabolic effects.  Examples of SARMs include andarine S-4 and enobosarm, with others in various stages of development.


o   Other Anabolic Agents: There are other hormones and peptides that are normally produced in the body to stimulate the production of hormones that may have anabolic properties.  Because these agents can be produced exogenously, athletes may inject them as doping agents.  Examples include gonadotropin releasing hormone, growth hormone releasing peptide and clomiphene (also classified as an anti-estrogen drug).


o   Supplements that contain anabolic agents: In 1994, Congress passed the Dietary Supplement Health and Education Act (DSHEA), which eliminated broad U.S. Food and Drug Administration (FDA) oversight of supplements.  Supplements include herbs, plant derivatives and extracts, and are often taken by athletes in an attempt to expand on what cannot be provided by diet alone.  Unfortunately, because of DSHEA, there is no independent testing of ingredients in supplements, and there is no government research or oversight with regard to supplement effectiveness, adverse effects, or interaction of ingredients. Studies have demonstrated that up to 20 percent of supplements – particularly supplements that claim anabolic or body-building effects – are tainted with prohibited anabolic agents.  Thus, an athlete may innocently take a supplement to improve his or her performance, and may then test positive for a banned substance.


Some athletes have a sense of invincibility, and this includes taking anabolic agents without fear of side effects.  However, there are numerous known side effects of anabolic agents, such as:

o   Psychiatric and emotional disturbances, including rage and psychotic break from reality.

o   Musculoskeletal injury, including tendon weakness and rupture.

o   Cardiovascular injury, including premature myocardial infarction (heart attack) from fatty blockage of coronary arteries.

o   Cancer risk, especially prostate cancer in males.

o   Infertility.


·         Masking Agents: Masking agents are taken with the intent of hiding other performance-enhancing drugs.  Since most drug tests are through analysis of urine, a masking agent can theoretically affect the chemical analysis of urine, thereby interfering with analysis.  Diuretics are the simplest and most classic form of masking agents.  Diuretics increase urine production and excretion, and therefore dilute the urine.  In a very dilute urine sample, it will be more difficult to detect other drugs.  Diuretics and other masking agents do not enhance performance, but can cause serious side effects such as dehydration and abnormally low potassium in the body.

·         Stimulants: Stimulants are drugs that increase alertness, attention, and energy, while also elevating blood pressure, heart rate and respiration.  Historically, stimulants have been used to treat asthma, obesity, and certain neurological disorders; however, as their potential for abuse and addiction became apparent, the medical use of stimulants has become more constricted.  Today, stimulants are used to treat narcolepsy, attention deficit hyperactivity disorder (ADHD), and occasionally depression.  Stimulants mimic the effects of the brain chemicals norepinephrine (adrenaline-like chemical) and dopamine (pleasure chemical).


Stimulants are the most unique of the performance-enhancing drugs because they are also commonly used to treat ADHD, and they are used in a widespread manner as recreational drugs of abuse.  ADHD is a disorder that comprises inattention, hyperactivity and impulsiveness. A common medical treatment for ADHD is prescription stimulants.  In 2013, it was estimated that ADHD affects between 8 to 20 percent of the adolescent and young adult population.  However, ADHD often co-exists with other psychiatric conditions, as noted in Figure 1.


Figure 1. ADHD and Other Psychiatric Conditions

In addition, stimulants are increasingly used as cognitive enhancement medications in individuals who do not suffer with ADHD or other psychiatric conditions, as noted in Figure 2.


Figure 2. The Spectrum of Stimulant Use

Thus, there are often imprecise boundaries between the use of stimulants as therapy and wellness enhancement. 


Commonly used stimulants include:

o   Dextroamphetamine stimulants include Dexedrine and Adderall.

o   Methylphenidate stimulants include Ritalin and Concerta. 


Both classes of drugs act in the brain in a similar fashion by enhancing the effects of norepinephrine and dopamine.


Stimulants may be used as PEDs because they increase alertness, attention and energy, and may also increase aggressiveness.  Performance-enhancing stimulant use has been documented in a wide variety of sports, including baseball, cycling, football and track and field. Stimulants may be used as recreational drugs to help increase wakefulness and energy in the setting of a long party, and often as a counter-medication to alcohol or narcotic use.  Stimulants may be used “off-label,” meaning that they have not been prescribed to the individual for ADHD or another legitimate medical condition, for cognitive enhancement.  In this setting, stimulants are most often utilized in colleges with competitive academic standards.  Indeed, surveys indicate that 16 to 60 percent of college students use stimulants for non-medical/cognitive enhancement use.


Despite the widespread use of stimulants as “neuroenhancing” drugs (e.g., drugs taken to improve cognition), scientific evidence does not support the conclusion that stimulants are cognitive enhancers.  However, the effects of stimulants on the user’s emotions and feelings are an important contributor to the user’s perceptions of improved academic performance.  For example, if you take a stimulant for the purposes of studying, and you feel more awake and ‘stimulated’ during the study process, you are likely to believe that your cognitive performance will be improved.


Although many stimulant users do not believe they are involved in criminal activity through non-prescription use, it is important to note that stimulants are Schedule II medications, which is the same schedule as narcotics.  Stimulants are Schedule II drugs because there is a considerable potential for abuse and addiction.  Distributing stimulants illegally is a felony.  Because of the potential for stimulant abuse, many institutions are tightening rules on the diagnosis of ADHD and subsequent stimulant prescriptions.


In addition to addiction, there are several potential side effects of stimulants, including:

·         Psychiatric disorder, including rage, paranoia and psychosis.

·         Dangerous elevation of blood pressure, with subsequent heart attack or stroke.

·         Irregular heartbeat and seizures.

·         Elevated body temperature, which, if combined with any combination of dehydration and sickle cell trait, can cause rhabdomyolysis and death.


Other stimulants:

·         Cocaine is a recreational drug with a very narrow window for medicinal use.  Cocaine is obtained from the coca plant, and it works in a way very similar to prescription stimulants by increasing brain norepinephrine and dopamine.  Cocaine can be snorted, smoked, or injected, and all of these routes of administration lead to a very rapid onset of action of the drug, which is its recreational appeal.  Potential side effects of cocaine are similar to prescription stimulants, but are amplified when large doses are taken in a short period of time.

·         Caffeine originates naturally in 63 species of plants and is the most widely consumed drug in America.  Caffeine is most commonly ingested in coffee and tea, but is also present in chocolate, beverages, over-the-counter pills, and energy drinks.  Caffeine exerts its brain effect by blocking adenosine receptors.  Adenosine normally inhibits activity, so blocking its effect leads to increased energy and wakefulness. 


Caffeine doses vary, depending on the drink or food (See Caffeine/Energy Drink Posterfor more details).  When used in a ‘societal’ dose (e.g., a cup of coffee or tea) caffeine has a mild stimulant effect and is usually well tolerated.  Caffeine is regulated in sport when taken in large doses, and in such a setting is considered a doping agent.  However, large doses of caffeine, especially over 500mg, can cause heart palpitations, restlessness, insomnia, irritability, anxiety and reduced cognitive and physical performance.


·         Energy drinks, like supplements, are not regulated by the FDA.  In addition to containing potentially large doses of caffeine (often not stated on the label), energy drinks may be adulterated with amphetamine-like compounds, specifically dimethylamylamine (DMAA).  Energy drinks also commonly contain amino acids and other additives.  More than a third of teenagers consume energy drinks. Energy drinks and other over-the-counter supplement products have become a possible source of positive drug tests at both the Olympic and NCAA level.  Because energy drinks may be consumed rapidly, the user may inadvertently ingest a large dose of caffeine, possibly with other stimulants, and can develop similar side effects to other stimulants.

·         Beta-2 agonists are medications that are commonly used to treat asthma.  When inhaled, they lead to immediate bronchodilation.  Asthma is a condition in which the airways become constricted, and beta-2 agonist use leads to immediate symptomatic relief.  Weak evidence exists that beta-2 agonists may improve performance as a stimulant, and for this reason athletes must obtain approval for their use. 


·         Blood Doping and Erythropoietin: Blood doping refers to the practice of intravenously infusing blood into an individual in order to induce erythrocythemia (increase the amount of red blood cells).  The procedure may be autologous (one’s own blood) or homologous (donated blood).  Erythropoietin is a naturally occurring hormone that originates in the kidney, and that regulates the amount of red blood cells in the body.  Erythropoietin can now be produced synthetically and administered by way of injection.  When used for non-therapeutic purposes, erythropoietin produces changes in the body similar to blood doping, which means that there are more red blood cells available for transferring oxygen.


Blood doping and erythropoietin are used as PEDs by athletes who wish to improve their endurance.  By increasing the amount of red blood cells available to transport oxygen to the contracting muscle, such doping improves aerobic power.  This means that in long distance events such as cycling, running and cross-country skiing, the athlete has more capacity to utilize oxygen. 


Side effects of homologous blood transfusions include serious immune reactions and the transfer of viral diseases such as hepatitis and HIV.  Autologous blood doping and erythropoietin use carries with it the potential for too many red blood cells in the body, which can cause hypertension, congestive heart failure and stroke.


Nutrition and the Injured Athlete

Injuries are often an unavoidable aspect of participation in physical activity. Nutrition may not be able to prevent injuries related to overuse or improper training; however, nutrition can play a role in how fast a student-athlete recovers.1 Poor nutrition can lead to conditions that increase the risk of injury. Exercise related fatigue, which is characterized by an inability to continue exercise at the desired pace or intensity, is just one example. Nutritional causes of fatigue in athletes include inadequate total energy intake, glycogen depletion, dehydration and poor iron status.2

For nutrition to aid in injury prevention, the body must meet its daily energy needs. Insufficient daily overall calories will limit storage of carbohydrate as muscle or liver glycogen. Poor food choices day after day can lead to the deficiencies resulting in chronic conditions, such as iron deficiency or low bone mineral density.2 Therefore, total dietary intake over the course of days, weeks and months must be adequate. Whether the focus is injury prevention or rehabilitation, getting adequate calories, carbohydrates, protein, fluids, vitamins and minerals are all important.

Prevention of dehydration and muscle glycogen depletion necessitates maximizing muscle glycogen stores prior to and during exercise, as well as beginning activity in a euhydrated state. Following a proper hydration schedule will help athletes maintain their hydration status.

Iron deficiency can occur in both male and female athletes; however, it has been estimated that approximately 60 percent of female college athletes are affected by iron deficiency.3 Many factors can contribute to iron loss in the female athlete including menstruation, inadequate dietary iron intake, gastrointestinal bleeding and sweat loss, among others.3 An iron adequate diet minimizes the consequences associated with iron deficiency, which are impaired athletic performance, immune function and cognitive function.3

For female athletes there is yet more to consider. Research shows a positive relationship among injury, disordered eating, menstrual dysfunction and low bone mineral density.4 A recent update on stress factors in female athletes suggests that early screening for the female athlete triad and other nutrition strategies be part of the preventative strategies against the overuse injury.5

Many student-athletes faced with an injury are quick to worry about their body composition. Fears such as gaining weight or muscle turning to fat are common. These are legitimate concerns considering an injury likely leads to a drastic change to a student-athlete’s training. To reduce the risk of unwanted weight (fat) gain and to help the athlete minimize loss of lean mass, special nutritional considerations must be paid to the injured athlete. Energy intake and distribution will need to be reevaluated to match a decreased volume and intensity or to aid in rehabilitation and recovery.5

There are a wide range of athletic injuries that can take student-athletes out of the game and the nutritional concerns can vary greatly for each. Bearing an injury requires making modifications to training so that proper rest and recovery can occur. Because an athlete’s nutrition plan directly supports the training plan, this also requires modification to the amount of food that is consumed. During rehabilitation and recovery, the specific nutrient needs are similar to those for an athlete desiring muscle growth, with the most important consideration being to avoid malnutrition or nutrient deficiencies.

Here are the specifics on how to eat for optimal recovery and healing while preventing weight gain:

·         Focus on energy balance. Calories are necessary for the healing process and consuming too few will likely slow the healing process. However, to prevent weight gain while training is on hold, total daily caloric intake likely needs to decrease.

·         Focus on a variety of whole foods. Many athletes are accustomed to consuming additional calories through convenience foods and drinks such as sports drinks, bars, shakes or gels. These sources of fuel are better left for times of intense training and higher energy needs. Instead, focus on foundation of whole foods that includes lean proteins, fiber-rich whole grains, fruits, vegetables, low-fat dairy, and healthy fats such as nuts and seeds.

·         Avoid foods with high amounts of simple sugars or dietary fats. These foods tend to be less nutrient-dense as compared to whole food choices.

·         Student-athletes should be reminded to consult with a board certified sports dietitian and speak with their athletic trainer prior to taking any form of supplementation.

This article was written for the Sport Science Institute by SCAN Registered Dietitians (RDs). For advice on customizing an eating plan for injury prevention or after injury, consult an RD who specializes in sports, particularly a Board Certified Specialist in Sports Dietetics (CSSD). Find a SCAN RD at

1.)    Tipton KD. Nutrition for Acute Exercise-Induced Injuries. Annals of Nutrition and Metabolism. 2010;57(suppl 2):43–53

2.)Sports, Cardiovascular, and Wellness Nutrition Dietetic Practice Group, Rosenbloom C, Coleman E. Sports Nutrition: A Practice Manual for Professionals, 5th edition. Academy of Nutrition and Dietetics: 2012.

3.) Rauh, MJ, Nichols JF and Barrack MT. Relationship Among Injury and Disordered Eating, Menstrual Dysfunction, and Low Bone Mineral Density in High School Athletes: A Prospective Study. Journal of Athletic training. 2010; 45(3):243-252.

4.Cowell BS, Rosenbloom CA, Skinner R, Sumers SH. Policies on screening female athletes for iron deficiency in NCAA Division I-A institutions. Int J Sports NutrExercMetab. 2003;14:104-120.

5.) Chen, Yin-Ting, Tenforde, Adam and Fredericson, Michael. Update on Stress Fractures in Female Athletes: Epidemiology, Treatment, and Prevention. Curr Rev Musculoslel Med (2013) 6:173-181.

6.) Tipton KD. Dietary strategies to attenuate muscle loss during recovery from injury. Nestle NutrInst Workshop Ser. 2013;75:51-61

John Parsons named new director of NCAA Sport Science Institute

By Brian Burnsed The NCAA’s Sport Science Institute is welcoming a new expert in January. John Parsons, who has spent more than two decades studying, practicing and teaching sports medicine and athletic training, will join the NCAA as...

ADHD and the Student-Athlete

By Christopher J. Richmond, Ph.D., LP, LMFT

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurobiological disorders of childhood and often continues through adolescence and adulthood. In the past, some individuals and groups believed that young adults would simply “outgrow” ADHD. However, we’ve learned that some young adults develop strategies to mitigate ADHD symptoms, but many find that these symptoms persist into adulthood. Population surveys reported by the American Psychiatric Association indicate ADHD occurs in approximately 5 percent of children and 2.5 percent of adults.

Many people assume that student-athletes are emotionally healthy in the same ways that they are assumed to be physically healthy. However, just as student-athletes may suffer with physical illnesses and injuries, they are also vulnerable to mental health disorders, including ADHD.

The three core symptoms of ADHD are:

  1. Inattention.
  2. Hyperactivity
  3. Impulsivity

Each core symptom includes several additional symptoms. ADHD symptoms are often noticed by student-athletes in situations such as listening to a lecture in class, completing homework assignments, talking with friends or listening to a coach’s instructions.


The core ADHD symptoms of inattention, hyperactivity and impulsivity, as outlined in the newDiagnostic and Statistical Manual of Mental Disorders, (5th ed.; DSM-5; American Psychiatric Association, 2013) are listed in the table below. In order to be diagnosed with ADHD for either the Inattention or the Hyperactivity/Impulsivity symptom set an individual (17 years of age or older) must have at least five of the nine symptoms listed below for at least six months. And they must have been severe enough to interfere with the patient’s quality of life (See Table 1). For the student-athlete this means that ADHD symptoms are usually present on a daily or weekly basis both within the academic setting and in the athletic, social, job or home setting. To confirm a diagnosis of ADHD, there must also be evidence that there were ADHD symptoms prior to age 12. Table 2 lists the three ADHD presentations.


Case Study

At Ferris State University, student-athletes are primarily referred for an ADHD assessment by a certified athletic trainer. Athletic trainers may refer a student whom they suspect has ADHD because of difficulties in the classroom, on the field or both. Athletic trainers also refer students that have been previously diagnosed and are currently taking a stimulant medication, but lack proper documentation of an ADHD diagnosis. This scenario is common at Ferris State. Often, a student-athletes is diagnosed by a family doctor or primary care physician without a comprehensive assessment, and that physician will make a diagnosis of ADHD based upon the results of just one rating scale assessment or a short diagnostic-focused conversation with the patient.


Evaluation Process

After the referral has been made for the ADHD assessment, the student-athlete is evaluated at the Ferris State Health Center to assess current symptoms. The Health Center physicians utilize an ADHD screening assessment to determine the presence and severity of symptoms. The physicians then use the data from this assessment to determine whether or not a student should be evaluated further. In this case, the health center physician will refer the student-athlete to the counseling center for a comprehensive assessment. Following the completion of this assessment, which typically spans the course of four to five sessions, the report is released (with the client’s permission) to the health center and the athletics department.

The ADHD assessment protocol employed at the Ferris State Counseling Center follows a multi-method approach, which includes assessment procedures such as interviews, rating scales, psychological tests and a review of past academic records. A multi-method approach to the assessment of ADHD is important because there is no single procedure that addresses all of the criteria for ADHD. ADHD interviews typically fall within one of three areas: (1)structured; (2)semi-structured; or (3) unstructured. The Ferris State Counseling Center protocol utilizes a semi-structured assessment during the first session, which is adapted from the standard intake interview. The protocol employs a structured interview at the second session that more closely examines each symptom of ADHD. This structured interview is geared specifically to the adult population and assesses symptoms that were present during childhood and adulthood.

The ADHD rating scales generally fall within either a broad-band or narrow-band category. The broad-band rating scales assess a wide range of behaviors that typically include psychological symptoms beyond those specific to ADHD such as depression and anxiety, which are often associated with ADHD symptoms. The narrow-band rating scales more exclusively assess ADHD symptoms. Some ADHD rating scales include both a self-report and observer-report version. It is advantageous to collect important ancillary data from close family members or friends.

The psychological tests are typically measures of sustained attention. The continuous performance test is one of the most common diagnostic tests used in the assessment of ADHD. Most are computer-based assessments of attention. For example, the student-athlete may be asked to press the space bar every time the letter A appears on the monitor. These continuous performance tests detect brief lapses of attention through omission errors (lack of attention) and commission errors (impulsive response).

The last assessment area pertains to the review of academic records. This review typically consists of an evaluation of elementary and middle school report cards. The new diagnostic criteria indicate that there must be evidence of ADHD symptoms prior to age 12. Most report cards assess classroom behavior and study habits, which typically include areas closely related to ADHD symptoms. For example, “listens attentively” and “follows directions” are common assessment areas specific to study habits. Teacher comments in the narrative form may also indicate problems related to ADHD.

Due to the complexity of a comprehensive ADHD assessment, they should be completed by a professional—namely, a psychologist, psychiatrist or medical doctor with experience in this area. It is the experience of this author (as the psychologist providing the assessment), that having a close working relationship with the athletic trainers and physicians on campus facilitates an effective and efficient protocol in managing student-athletes with suspected ADHD.



ADHD treatment is often multi-disciplinary in nature, and may include any combination of cognitive-behavioral strategies, goal-oriented strategies, nutritional guidance, psychotherapy and medication management. Stimulant medications are the mainstay of pharmacologic treatment of ADHD (commonly prescribed ADHD stimulant medications are listed in Table 3).


Stimulant medications are NCAA banned substances, and their use requires the institution to maintain documentation on file and submit a medical exception request, using the NCAA medical exception ADHD reporting form, in the event of a positive drug test. The documentation must include a written report of the evaluation conducted to support the diagnosis of ADHD, and medical treatment notes from the prescribing physician. Sometimes, anti-depressant and other medications are used in ADHD treatment, and these drugs are not prohibited. If the health center physician recommends a stimulant medication based upon the outcome of the report, he or she must complete the NCAA medical exception ADHD reporting form, which can be found here.



American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders(5th ed.). Arlington, VA: American Psychiatric Publishing.

Last Updated: Nov 12, 2013

Helmets Off

By NCAA Sport Science Institute

There has been a trend in professional and college football teams to utilize “Throwback” or “Third” uniforms.  Uniform changes have, in some instances, involved a change in helmet.  The NCAA Sport Science Institute does not have data with regard to frequent helmet changes and player safety or dislodged helmets; however, we do know that a properly fitted helmet is important in order to help assure that the primary function of the helmet remains intact.

The ‘Helmet Off’ Rule in college football states that if a player’s helmet comes completely off through play, other than as the direct result of a foul by an opponent, the player must leave the game for the next down.  The game clock will stop at the end of the down.  The player may remain in the game if his team is granted a charged timeout.  The timeout allows for the options of both keeping a player in a game at a critical moment while also allowing the equipment staff to adjust the helmet before the player returns to the game.

The ‘Helmet Off’ rule is an important component of helping to assure player safety in college football.  An analysis of dislodged helmets reveals a slight upward trend in helmets off during games in all conferences when the 2012 season is compared to the 2011 season. This is likely because the QwikRef system was utilized in 2012, which was much more accurate than the procedures used for 2011.  Table 1 summarizes results for 2012.


Table 1. 2012 Total Helmets Off By Football Bowl Subdivision (FBS) Conferences Per Week



Tables 2-4 show a downward trend in helmets off as the 2012 season moved from Week 1 through the end of the season, although the trend is less linear in the football championship subdivision (FCS) and Division II schools.  A similar seasonal progression downward trend was noted in 2011. 


Table 2. 2012 FBS Average Helmets Off Per Game Per Week




Table 3. 2012 FCS Average Helmets Off Per Game Per Week


Table 4. 2012 Division II Average Helmets Off Per Game Per Week

We will continue to monitor helmets off throughout the season.  Meanwhile, it is important to take note of any upward trends in dislodged helmets at your institution, and to assure that every helmet is fitted properly (See NCAA Helmet Fit poster for more information to share with your student-athletes).

Table 5. Football Bowl Subdivision Week 4 Average Helmets Off Per Game

The NCAA Budget: Where the Money Goes

The NCAA funds many programs directly supporting the academic needs and wellbeing of student-athletes. NCAA Chief Financial Officer Kathleen McNeely describes the sources of the Association’s revenue and how it is distributed.

How can the NCAA be a nonprofit organization when it generates so much revenue?

The NCAA maintains its nonprofit status because it is an association of colleges and universities sharing a common academic mission. Every year, the NCAA and its members equip more than 460,000 student-athletes with skills to succeed on the playing field, in the classroom and throughout life.

Where does the NCAA’s revenue come from?

Television and marketing rights fees, mostly from the Division I men’s basketball championship, generate 90 percent of revenues. Championship ticket sales provide most of the remaining revenue. Current revenues total approximately $800 million.

How are NCAA funds distributed?

Ninety-six percent of NCAA expenses benefit student-athletes at member schools through services or direct distributions. The NCAA supports operational expenses and student-athlete travel expenses for 89 national championships in 23 sports. The association also provides catastrophic-injury insurance coverage for all student-athletes and various scholarship, grant and internship programs. The NCAA and member schools together award more than $2.4 billion in athletic scholarships every year to more than 150,000 student-athletes.

The NCAA helps member schools pay for expenses related to the number of scholarships they provide and sports they sponsor. As a school provides more opportunities to student-athletes, it receives larger reimbursements. Every year, the NCAA provides almost $100 million to enhance academic opportunities and help student-athletes who need educational material, clothing and emergency travel expenses.

The NCAA distributes additional funds to Division I schools that are successful in the men’s basketball championship, since those programs effectively make basketball revenue possible. Division I conference grants are provided to help develop athletics administrators and coaches.

Division II and III also have smaller distribution and grant programs currently totaling about $15 million.

How much money does the NCAA spend on producing championships?

More than 54,000 student-athletes experience the thrill of participating in an NCAA championship every year. The NCAA’s championship expenses support operational expenses, team transportation, per diem costs, sport committee expenses, fan-appreciation events and programs saluting student-athletes. The NCAA currently spends $85 million on Division I championships, $23 million on Division II championships and $21 million on Division III championships.

What are the NCAA’s operating expenses?

With most revenue allocated to supporting student-athletes through various programs, the remainder is used to administer the day-to-day operations of the NCAA. This includes the costs of running the national office and supporting its 500 employees, who administer 89 championships, maintain a governance structure sustaining approximately 1,100 member schools, provide educational services to coaches and athletics administrators, and manage financial systems for membership.

Other annual operating expenses include student-athlete catastrophic insurance, health and safety initiatives, legal support and governance committee travel.

How much are the NCAA’s current assets?

Under the direction of the NCAA Executive Committee, comprised of presidents and chancellors from all three divisions, the NCAA sets aside assets in reserve to protect NCAA membership in the future. The NCAA currently has approximately $530 million in unrestricted assets, including an operating reserve of $84 million, a $34-million reserve for capital replacement and a quasi-endowment of $282 million. The quasi-endowment is specifically intended to protect NCAA membership in the event that media revenue dollars are not received due to an interruption in the men's basketball championship. The quasi-endowment policy, as set by the Executive Committee, has a targeted goal of $380 million.

Excess assets not allocated to a reserve account are distributed back to Division I schools as a supplemental distribution. In February, 2013, the NCAA’s supplemental distribution was $42 million.

How does the NCAA support student-athlete wellbeing?

The NCAA sponsors a number of health and safety initiatives, including a program collecting and analyzing injury incidence data in order to help create safer competition, championship and year-round drug testing that helps protect student-athletes and ensure fair play, and grants promoting health and safety research as well as the prevention of alcohol and drug abuse on college campuses.

Last Updated: Oct 15, 2013

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