Examination of Musculoskeletal System Problems and Affecting Factors in CrossFit Sports
Condition: CrossFit
Study type: Observational

Summary: 
      This study aims to determine the relationship between musculoskeletal system problems and
      physical risk factors in CrossFit athletes. Athletes who do CrossFit training in the Turkish
      Republic of Northern Cyprus and meet the inclusion criteria will be included in the study.
      Individuals will first be asked about their personal information, when they started CrossFit,
      and their previous injury information. Then, the muscle strength, functionality, stability,
      balance of the lower extremity muscles and body posture in different positions will be
      evaluated with the determined tests. Evaluations are in a single day and in total 45 minutes.
      is planned in.
    

Detailed description: 
      CrossFit was developed by Greg Glassman in 1995 to increase core strength and general muscle
      strength and conditioning. It has grown in popularity around the world since it was first
      developed. Today, more than 15,000 CrossFit gyms operate around the world. CrossFit; It is a
      multimodal exercise training performed at high intensity, covering many functional movement
      models in a single exercise session. CrossFit is done with high-intensity, functional
      movements called "Workout of the Day" (GA). In workouts, exercises are performed quickly,
      with little or no rest between reps and sets. CrossFit training, which focuses on constantly
      changing functional movements; olympic weightlifting, powerlifting, sprint, plyometric,
      calisthenics, gymnastics and rope climbing is a mix of exercise models that are difficult to
      categorize. Each GA has its own special name and is performed with a certain combination of
      exercises. Although the nature of each session varies between affiliates, each session is
      typically 1 hour and includes a specific work of warm-up, strength or skill technique.
      Although GAs are performed in groups, the warm-up or cool-down times may differ according to
      the needs of the individuals.

      Ángel Rodríguez et al. In their study on the epidemiology of injury and risk factors in
      CrossFit in 2020, they reported that the risk of injury in these sports modalities is similar
      when compared to other weightlifting and powerlifting, but challenging training programs
      increase the risk, especially if not performed in the right position. They emphasized that
      excess exercise volume and number of training sessions in CrossFit can cause early fatigue,
      higher effort perception, and a risky movement practice.

      Mehrab et al. In another study conducted in 2017, they examined the injury incidence of Dutch
      CrossFit athletes and the injury incidence of athletes participating in CrossFit was 56.1%
      and the most injured body parts were 28.7% shoulder, 15.8% waist and 8.3% knee. have
      reported. The most common exercises causing injury were squat 22.0% and deadlift 18.0%. It
      has been stated that advanced athletes are more seriously injured than beginner athletes, and
      people with 3 years of CrossFit experience are 3.3 times more likely to be injured than those
      with 2 years or less experience. According to the review of 2020, it is reported that
      tendinopathies, joint injuries and muscle injuries are seen most frequently in Crossfit.

      Given the growing popularity of CrossFit, avoiding potential risks from poor practice and
      proper training are essential for athletes. Analysis of injury patterns is an essential part
      of this process, enabling athletes, coaches, and health professionals to become better
      informed about inappropriate habits that harm physical integrity and how it can be improved.
      When we look at the literature, there are few studies that determine the physical risk
      factors of CrossFit athletes, and there is no study that examines the relationship between
      musculoskeletal injuries and risk factors. Our study will be the first study to determine the
      relationship between musculoskeletal system problems and physical risk factors of CrossFit
      athletes in the TRNC. The risk factors that emerged as a result of the study will be shared
      with the athletes, and the prevention of possible future injuries and the improvement of
      public health will be tried.

      Hypotheses:

      H01: Balance is similar in CrossFit athletes with and without musculoskeletal system
      problems.

      H02: Functional performance is similar in CrossFit athletes with and without musculoskeletal
      system problems.

      H03: Stability is similar in CrossFit athletes with and without musculoskeletal system
      problems.

      H04: Muscle strength is similar in CrossFit athletes with and without musculoskeletal system
      problems.

      H05: Posture is similar in CrossFit athletes with and without musculoskeletal system
      problems.

      Material and Method:

      Athletes who do CrossFit training in the Turkish Republic of Northern Cyprus and meet the
      inclusion criteria will be included in the study. The sociodemographic information of the
      individuals and in addition to this information, the training characteristics of the
      individuals (daily training time, etc.), the time to start CrossFit will be questioned. Then,
      lower extremity muscle strength, function, posture in lateral and squat positions, upper and
      lower extremity stability and balance will be evaluated. Evaluations will be made within a
      single day.

      In this study conducted to determine the relationship between musculoskeletal system problems
      and physical risk factors in CrossFit athletes; According to the power analysis using the
      G*Power program, in 2020 Lima et al. With reference to his study titled "Epidemiology and
      associated factors for CrossFit-related musculoskeletal injuries: a cross-sectional study",
      O.R. Its value was determined to be 2.25. Accordingly, the sample size required for 80%
      (1-β=0.95) power at α=0.05 level was calculated as 67 people. While 67 people participated in
      the evaluation, our study was completed with 65 people because 2 people who experienced
      health problems during the study left the study.

      Evaluations to be applied to the Subject:

      Socio-demographic Evaluations:

      In the first evaluation, socio-demographic information such as age, height and body weight of
      individuals will be obtained through a form. In addition to this information, the training
      characteristics of the individuals (daily training time, etc.), the time to start CrossFit,
      the age of sports (how many years he has been training regularly) will be questioned.

      Extended Nordic Musculoskeletal Questionnaire:

      Turkish translation and cross-cultural adaptation Alaca et al. The Extended Nordic
      Musculoskeletal Questionnaire (GNSSA) is an assessment questionnaire used for the evaluation
      of musculoskeletal disorders. GNKİSA is a questionnaire that evaluates the presence, onset,
      incidence, results and effects of musculoskeletal pain in 9 regions of the body, including
      neck, shoulder, back, elbow, hand/wrist, waist, hip/thigh, knee, foot/ankle. . In this
      questionnaire, the age of onset of pain, hospitalization due to pain, changing the place of
      duty, having pain in the last year, last month and today are questioned. In addition, it is a
      questionnaire that can be filled by oneself or by interviewing the person, questioning
      whether the current pain affects the individual's work/home life, applying to a
      doctor/physiotherapist, taking medication and getting a report. Subjects are asked to mark
      the location of the pain on the body diagram. A high score indicates musculoskeletal pain.

      Lower Extremity Functional Performance Evaluation:

      Individuals' lower extremity functional performance will be evaluated with the Single Leg
      Jump Test (TBS). It is used in athletes and healthy young individuals in terms of being easy
      to use and not requiring equipment for the evaluation of functional performance during the
      return to sports phase. TBST validity and reliability were reported as 0.85 with ICC ratio.
      For the test, 2 measuring tapes are affixed to the plastic rods at an angle of 180 degrees
      and it is requested to stand on the dominant foot with the tip of the toe to the starting
      point of the tape measure. While the individual is standing on the dominant right leg, the
      other leg is bent at the knee and asked to jump forward and the point where the individual
      falls (heel projection) is marked. Care should be taken to keep the hands on the waist while
      jumping. If he loses his balance while falling to the ground and gets support from the other
      foot, the test is considered invalid and repeated. Jumping was repeated 3 times for both
      extremities. Jump distance is calculated by measuring with a tape measure in centimeters and
      taking the average value.

      Evaluation of Lower Extremity Isokinetic Muscle Strength:

      Strength values of isokinetic lower extremity quadriceps femoris and hamstring muscles will
      be measured by using an isokinetic dynamometer device (Humac Norm Isocynetic Dynanometer). In
      addition, the knee Q/H ratio will be calculated. Before starting the test, the test protocol
      will be explained in detail to the athletes and they will be warmed up with a 10-minute jog
      run. The movements of the athletes will be evaluated with a test protocol with 5 repetitions
      at 60º/sec and 20 repetitions at 180º/sec. A 1 minute rest will be given between
      measurements. Before each angular velocity, individuals are allowed to make 3 repetitive
      trials, and the tests will be applied after a rest period of 10 seconds. The test will be
      performed in a sitting position, the body will be positioned upright, the hips will be in 90°
      flexion, and the body and waist will be fixed in order to prevent compensation. Measurements
      to be applied in sitting position will be adjusted at 90° knee flexion and knee extension
      range of motion. The test will be applied bilaterally. total work; Joules (J) and peak torque
      will be recorded in Newtonmeters/kilogram (Nm/kg). In addition, the Shoulder Q/H ratio will
      be calculated.

      Closed Kinetic Chain Upper Extremity Stability Test:

      The reliability of the Closed Kinetic Chain Upper Extremity Stability Test was determined by
      Oliveira et al. made by Dynamic stability of the shoulder will be evaluated with KKZÜEST.
      This test, which is normally done in the push-up position, can be modified and applied in
      such a way that the knees are flexed for the elderly. The tester first explains the test
      position to the athlete, then the test is started with the 'start' command and the test is
      finished with the 'stop' command. After the instructions and demonstration, 3 trials are made
      to teach the test and 5 seconds rest between each trial. Verbal cues can be given as needed
      during practice. Subjects will be placed in a push-up position with their hands 36 inches
      (91.44 centimeters) apart on 1.5 inches (3.81 centimeters) wide strips. While one hand is
      fixed on the ground, it is asked to raise the other hand, touch the band under the fixed hand
      and take it back to the starting point. The same movement is repeated for the opposite side
      and 15 seconds. The number of repetitions performed is recorded. The test is performed 3
      times and between trials, the participant is given 45 seconds. rest period is given. The
      average of 3 repetitions of the test is calculated using two formulas: test score and
      strength. The score is calculated as the average of 3 repetitions / height (m), Strength =
      68% body weight (kg) x the average of 3 repetitions.

      Closed Kinetic Chain Lower Extremity Stability Test:

      Closed Kinetic Chain Lower Extremity Stability Test, Arıkan et al. Its reliability and
      validity were made in 2021 by The test was developed to measure trunk and lower extremity
      strength, strength and stability of the whole body. In addition, this test provides
      assessment of functional lower extremity stability, static/dynamic control of the lower
      extremity (knee/hip) or trunk, and simultaneous activation/such coactivation of the
      quadriceps and hamstring muscles. The tester first explains the test position to the athlete,
      then the test is started with the 'start' command and the test is finished with the 'stop'
      command. In order to teach the test from the instructions and demonstration, 3 trials are
      made and 5 seconds rest between each trial. Verbal cues can be given as needed during
      practice. A stable base floor, mat and stopwatch will be used as equipment to measure the
      test. (KKZAEST) starting position is on the mat on the stable floor, the person lies on his
      forearms with his feet shoulder-width apart, toes in contact with the floor and his body lies
      in a straight line. While maintaining the starting position of the body, the individual is
      asked to bring one foot to the diagonal outer side of the other foot. After touching the side
      of the other foot, the foot returns to the starting position. Then the person performs the
      same movement with the other foot. The number of repetitions in 15 seconds is recorded as in
      the closed kinetic chain upper extremity stability test. Touches count each time the foot
      touches the side of the other foot and the floor. Three repetitions of the 15-second CCZAEST
      are performed with 1-minute intervals between each test. The test is performed 3 times and
      between trials, the participant is given 45 seconds. rest period is given. The average of 3
      repetitions of the test is calculated using two formulas: test score and strength. Score =
      average of 3 repetitions / average over height (m), Power = 68% body weight (kg) x average of
      3 repetitions.

      Upper Extremity Y Balance Test:

      UEYDT is used to determine the risk of injury in musculoskeletal problems and is the only
      test in the literature that evaluates both shoulder stabilization and core stability. The
      tester first explains the test position to the athlete, and then 3 attempts are made to teach
      the test and rest for 5 seconds between each attempt. Verbal cues can be given as needed
      during practice. With both hands shoulder-width apart, the measurement begins with the right
      hand on the stance plate and the left hand on the access cursor. By maintaining the push-up
      position, the distance reached with the left hand is recorded in 3 directions, first medial,
      then inferolateral and finally superolateral. The person returns to the starting point in a
      controlled manner without breaking the push-up position. Tests are repeated 3 times on both
      extremities. Upper extremity length to be used in scoring is determined by measuring the
      distance between the acromion and the longest fingertip with a tape measure. The combined
      reach distance is calculated with the formula [(maximum medial + maximal inferolateral +
      maximal superolateral) / (3 x upper extremity length)] x 100 using the best value reached for
      both extremities in that direction.

      Lower Extremity Y Balance Test:

      Lower extremity dynamic balance will be evaluated with the Y Balance Test. Y balance test is
      a modified form of star balance test. The reliability of the test has been proven with ICC
      values varying between 0.85-0.91. The tester first explains the test position to the athlete,
      and then 3 attempts are made to teach the test and rest for 5 seconds between each attempt.
      Verbal cues can be given as needed during practice. In the test setup, 3 measuring tapes are
      adhered to the plastic rods at an angle of 120 degrees. Individuals stand on one leg at the
      intersection of the three measuring tapes. With the other foot, it is requested to extend the
      tip of the toe towards these 3 directions, anterior, posteromedial and posterolateral. At
      this time, care is taken to ensure that the individual does not lose his balance by placing
      his hands on his waist, that the heel of the foot he is standing on does not rise from the
      ground, and that the toes of the extended foot lightly touch the tape measure. At the end of
      each test, the individual is asked to bring his or her feet to the side without losing
      balance and without touching the ground. Measurements are repeated if the individual is
      unable to maintain one foot balance on the platform, or if the outstretched foot kicks the
      pointer plate or cannot return to the starting position. The test will be repeated 3 times in
      each direction and the average will be recorded in cm. The length of the lower extremity
      (between the spina iliaca anterior superior and the medial 3malleolus) will be measured with
      a tape measure. The combined reach distance will be calculated with the formula [(maximum
      anterior + maximal posteromedial + maximal posterolateral) / (3 x lower extremity length)] x
      100 using the best value reached for both extremities in that direction.

      Posture Evaluation:

      Posture of the athletes in lateral and squat positions was reported by Hopkins et al. It will
      be measured with the PostureScreen Mobile® Application, whose validity and reliability study
      has been carried out by PostureScreen Mobile® Application is a valid and reliable application
      that allows individuals to evaluate their postures through photographs with the help of the
      camera system on devices with iOS and Android systems. The application, which provides the
      opportunity to evaluate the static posture of individuals in standing posture from the
      anterior, posterior and lateral aspects and the posture in the squat position from the
      lateral aspect, reports numerical deviations from normal posture. Postures of the athletes in
      lateral and squat positions will be done on the smartphone using the PostureScreen Mobile®
      App. The specific points determined in the application for the lateral and squat positions of
      the athletes will be marked using the touch screen on the photographs taken, and according to
      these points, the postural disorder values and the degree of the disorder will be calculated
      and reported for each variable in cm or degrees via the software.
    

Observational model: Other
Time perspective: Other
Sampling method: Probability Sample
Study population: 
        Athletes in the Turkish Republic of Northern Cyprus who have done CrossFit sport for at
        least one year, who train at least 2 days a week and between the ages of 20-45 will be
        included in the study.
      
Keywords: Musculoskeletal; CrossFit; Injury; Relationship; Risk Factors