1. Caring for the Female Wrestler What her Coach Needs to Know Carole Maître

2. The specificities of the Female Wresling I. Female wrestling is a recent Olympic Sport : since 2004 at Athenes Olympic Games The 1st World Championship Cadet in 1988 II. Female wrestling is a Weight Class Sport : this issue is in relation to the management of weight loss and the risk of amenorrhea and athlete triad III. A combinaison of technical, tactical training and general strength training which requires a high level of endurance and physical fitness with the risk of perineal dysfunction, linked to the imbalance between the strength of the abdominal muscles and the pelvic floor

3. The french elite female wrestlers A french observational study Questionnaire « the 10 main questions » Given to 9 elite female wrestlers

4. * Hormonal contraception ** urinary incontinence The 10 questions of sport gynecology A positive response is a starter to complementary exam

5. HYPOTHALAMUS Pituitary gland GnRH OVARIES FSH- LH Steroid hormones Slowdown of function To spare energy

6. The population 7 female wrestlers filled out the questionnaire An average age : 23 years old An average training : 20 hours per week

7. * Hormonal contraception ** urinary incontinence The results

8. DXA scan for BMD testing An unexpected higher BMD on postero -anterior spine site 2 DXA scan show a normal BMD at all the sites

9. Prevalence of amenorrhea in weight class sports 23,5% of amenorrhea in weight class sport M K Torstveit and J Sundgot-Borgen Br. J. Sports Med. 2005;39;141-147 54,6% of cycle disturbance in female boxers Trutschnigg & al Appl Physiol Nutri Metab 2008

10. Energy availability The mechanism involved Cycle disturbance and amenorrhea Total energetic expenditure Dietary energy remaining after exercise training

11. HYPOTHALAMUS Pituitary gland GnRH OVARIES FSH- LH Steroid hormones Low energetic availability Low Leptine Neurotransmitters

12. Low estrogen rate muscle skin vagina endotheliumbreastuterusbrain bone Energetic metabolism Lipid metabolism GH INSULINE AMP kinase Glycogen stock How could we fight ? How could we play to win?

14. Keep your attention on warning signs Unexpected counter- performance Difficulty to recover Repeated injuries with tendonitis Stress fracture and its repetition Difficulty to stay in the weight class Unusual necessity to loose weight quickly

15. The first line : the prevention Key points when a weight loss is necessary Need to keep the same Muscular Mass Decrease the FM with the goal of optimal FM from 18% to 20%. Adapt the decrease of calories by step ( 500 kcal) with ¾ vegetables and ¼ starchy food per meal The goal is a gradual decrease of Fat Mass 1 kg / 18 -15 days Keep the goal : the weight loss has to be reversible quickly For the junior female wrestlers when the weight is high and the fat mass optimal : discuss the possibility of changing the weight class A lot to win by loosing weight gradually !! With no impact on estrogen rate

16. The training increases the impact of estrogen on the energetic metabolism What happened with a quick loss of weight ?

17. The 2 nd line : non pharmacological treatment Taking care of all the warning signs tiredness, dysmenorrhea energy availibility a multi disciplinary team around female wrestlers

18. The 3 rd line of treatment Status of vitamin D Hormonal therapy but no scientific evidence of efficacy on improvment of bone density

19. Task Force Message Take care of all the symptoms and warning signs Amenorrhea is practical for the athletes, but it is at risk of stress fracture, decreasing the performance The best treatment is a stable energetic balance. It is the role of nutritionist, sport dietitian with all the staff More studies on female wrestling teams are necessary

20. Not necessary to change the diet update the hormonal status Pelvic floor Dysfunction

21. Clinical Case 1  FF Wrestling  20 years old  1m 60 -50 kg  26 h training / week  SUI : NO  Trigger factors…  Precautions like taps,tampons : yes

22. neverseddomsometimesoftenalways Sitting to standing up X Brisk walking X Running X Jumping X Long jumping X Landing X Weight lifting X Sudden movment X Abdominal contractionX

23. Clinical Case n°2  19 years old  1m 60 - 59 kg  training / week: 26 h  UI : sometimes 1-2 per day After 1 H training  Take precautions : Yes 1-2 per day

24. neverseddomsometimesoftenalways Sitting to standing up X Brisk walking X Running X Jumping X Long jump X Landing X Weight lifting X Sudden movment X Abdominal contraction X

25. Literature review Nulliparous Elite Female Athletes studypopulationAge (years) prevalenceSports at risk Nygaard15619 ± 328 %Gymnastics - Basketball - Tennis Thyssen29122,852 %Gymnastics Dance Aerobic Bo87 versus 75 control 15 – 3941 % / 39% Gymnastics – Aerobic Eliasson3512 -2280 %Trampoline Nygaard 1994; Thyssen 2002; Bo 2001 Eliassen 2002

26. 404 elite athletes into 3 groups High dynamic composant SHDC n 201 P: 35 % High abdominal contraction SHIAC : 132 P: 24% Sports without impact and Technical Sports WITC : 71 P: 13% Athletics: Middle,long distance running, sprint, high jump,long jump,hurdles, pole vault Athletics: hammer, shot put, discus, javelin Cycling BadmintonRowingSwimming BasketballBoxingRifle shooting GymnasticsJudoArchery PentathlonKarate Wrestling TKW Ice sportsFencing squashHorse driving Table tennis – tennisSynchronized swimming Skiing, Water skiing

27. The impact of the years

28. The SUI occured after 1 hour of training for 52% of elite female athletes A decreased strength of pelvic floor - 20% after 90 min of intensive exercises Ree Nygaard Acta Obstet Gynecol Scand 2007

29. Basic abdominal pressure + Contraction of the abdominal muscles The link between sports and SUI A high increased abdominal pressure On the levator muscles bundles

30. Imbalance between the high abdominal pressure and the resistance of the pelvic floor Impaired Pelvic Floor Function (strength + endurance) A loss of the benefit of abdominal muscle contraction that escapes through the pelvic floor

31. 224 24 SHN HIFIT versus 22 control Echo 3D – IRM On a Valsava maneuver Increased diameter of the elevator anal muscle 0,96 cm versus 0,70 cm p< 0,01 A bladder neck descent 22,7 mm versus 15,1 mm p=0,03 A larger hiatal area 21,53 versus 14,71 cm on the Valsava maneuver p < 0,01

32. Anatomical changes Kruger 2007

33. The UI discomfort and impact

34. I Unavoidable Taboo Denial A delayed diagnostic by the perception It seems necessary to promote a Prevention Plan

35. Task Force message : information Elite Athletes Information and Training Doc. video quiz internet  The good training of abdominal muscles  The regular pelvic floor training  Kegel exercises Elite Athletes Information and Training Doc. video quiz internet  The good training of abdominal muscles  The regular pelvic floor training  Kegel exercises Physicians congress, formationPhysicians Trainers, coach  Awareness of the risk  Working the abdominal muscle with exercises without perineal risk Trainers, coach  Awareness of the risk  Working the abdominal muscle with exercises without perineal risk

36. Prevention Plan for the Female Wrestlers 7 SESSIONS Session 1: To give a clear information concerning the anatomy and the goal of PF Training Session 1: To give a clear information concerning the anatomy and the goal of PF Training Session 2 3-4: to correct the back spinal curvatures and to increase the strength of PF Session 2 3-4: to correct the back spinal curvatures and to increase the strength of PF Session 5: to work the abdominal muscle contraction in hypopressive status Session 5: to work the abdominal muscle contraction in hypopressive status Session 6-7 : to control the acquisitions Session 6-7 : to control the acquisitions REGULAR REPEATED PELVIC FLOOR TRAINING

37. Conclusion coach trainer Exercise physiologist Sport dietitian Sport physician Sport gynecologist Technical staff The physiological systems are a factor of performance PLAY SAFE

38. THANK YOU carole.maitre@insep.fr

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