A prospective experimental randomised clinical pilot study to

compare three pre-exercise protocols for reducing hand and

forearm muscle injury in a population of elite climbers:

A comparison of Warm Up with Contract-Relax Stretching,

Warm Up with Static Stretching, and Warm Up only

protocols.

________________________________________________
Submitted in partial fulfilment

for the degree of Bsc (Hons) Physiotherapy

Awarded by the University of Liverpool

Student number: 200962245

January 2017

Words

Page i
Abstract:
__________________________________________

Background and Literature Review: Climbing at an elite level places a great strain
on the muscles of the hand and forearm (Koukoubis et al., 1995). Injuring these
muscles may mean an enforced rest from their training routines or even missing out
on competition opportunities (Folkl et al., 2013). To counter this, many climbers
already complete some pre-exercise routines to protect against injury (Lion et al.,
2015). However, these practices are generally not evidence based and often
ineffective (McGowan et al., 2015; Lion et al., 2015; Josephsen et al., 2007). The
inclusion of stretching into sporting warm ups has been used for decades with the
aim of reducing sporting injury. Static stretching (SS) is a well-established technique
within sport (Le Sant et al., 2015; Medeiros et al., 2016) whilst Contract-relax
stretching (CRS) is more recent development and is only generally used by clinicians
(Kay, Husbands-Beasley and Blazevich, 2015). Robust evidence exists showing that
SS, CRS and Warm up (WU) can reduce stiffness of the muscle tendon unit,
theoretically making it more resilient to injury. However, past literature has yet to
provide consensus on whether this mechanism translates to real-world reductions in
injury incidence. This proposal therefore aims to answer the research question;
“In a population of elite climbers, is a combined intervention of CRS+WU more
effective in reducing the incidence of hand and forearm muscle injury than
interventions consisting of combined SS+WU or WU only?”
Methodology: Design: An independent groups prospective experimental
randomised clinical pilot study.
Independent Variable: Type of pre-exercise protocol. Dependent Variables:
Incidence of forearm muscle injury/1000 climbing hours, musculotendinous stiffness
(MTS) of hand and forearm muscles. Subjects and Recruitment: 33 elite climbers
recruited from climbing walls in the North-West. Intervention: One of three pre-
climbing protocols (SS+WU, CRS+WU or WU only). Intervention period will last six
months. Data Analysis: To determine whether any of the three groups are more
effective than the others; a multivariate multiple linear regression will be used.

Acknowledgements:
__________________________________________

Page ii
Firstly, I would like to thank my dissertation supervisor Chris Kitteringham for her help and
support. Without which it would have been impossible to complete this proposal.
I would also like to thank Mark Glennie and Nigel Callender for guidance on the topic of this
proposal.
Finally, I thank anyone who has given me their time to help make this piece of work better.

List of Abbreviations
__________________________________________

CCT- Clinical Control Trial

CRS- Contract-Relax Stretching
EMG- Electro-Myography

Page iii
FDP- Flexor Digitorum Profundus
FMD- Functional Muscle Disorder
LL- Lower Limb
MSKPA- Musculoskeletal Physiotherapy Assessment
PT- Physiotherapist
PTA- Physiotherapy Assistant
RCT- Randomised Controlled Trial
ROM- Range of Movement
SS- Static Stretching
UL- Upper Limb
UoL- University of Liverpool
WU- Warm Up

List of Figures
__________________________________________

1. Figure 1
2.

Page iv
List of Tables
__________________________________________

Table 1.
Table 2.
Table 3.

Page v
Table of Contents
__________________________________________

Page

Abstract i

Acknowledgments ii

List of Figures iii

List of Tables iv

1. Introduction 1

1.1 Research question

1.2 Research aims and objectives

1.3 Search Strategy

Page vi
2. Literature Review

2.1 Physiological mechanisms of WU

2.2 Warm Up and injury incidence

2.3 Physiological mechanisms for SS and CRS

2.4 Stretching and injury incidence

2.5 Combined WU and Stretching

2.6 Summary of Literature

3. Methodology

3.1 Hypothesis

3.2 Design

3.3 Randomisation

3.4 Population and subject recruitment

3.5 Inclusion and Exclusion criteria

3.5 Intervention and application

3.5.1 Baseline Measurements

3.5.2 Static Stretching protocols

3.5.3 Contract-Relax Stretching protocols

3.5.4 Warm Up protocols

3.6 Outcome measures and data collection

3.7 Analysis of data

3.8 Ethical Considerations

References

Page vii
 Appendices

Appendix 1: Search Strategy

Appendix 2: Letter to local climbing walls
Appendix 3: Advertisement poster
Appendix 4: Invitation letter
Appendix 5: Participant information letter
Appendix 6: Inclusion/exclusion criteria
Appendix 7: Consent form
Appendix 8: CRS group protocols and instructions
Appendix 9: SS group protocols and instructions
Appendix 10: WU only group protocols and instructions
Appendix 11: ROM measurement, digital goniometer and instructions
Appendix 12: % body fat; Jackson and Pollock (1985) skinfold calliper test
Appendix 13: Mass measurement; materials and instructions
Appendix 14: Height measurement; materials and instructions
Appendix 15: VO2 max; materials and instructions
Appendix 16: Subjective and objective physiotherapy assessment
Appendix 17: Randomisation process
Appendix 18: Proposed time frame of pilot study
Appendix 19: Data collection sheets

Page viii
 1. Introduction
_____________________________________________________

Rock climbing is a sport with a long and rich history. Traditionally practiced on

outdoor rock, the development of indoor climbing walls offering climbing in a more

controlled environment, has seen the sport’s monthly participation increase by 320%

since 1991(The British Mountaineering Council, 2016).

More recently, competitions on these indoor structures at a national and

international level have allowed climbing to be included as part of the 2020

Olympics.

This proposal will look at muscular injuries sustained whilst engaging in either Sport

Climbing (Figure 1) or Bouldering (Figure 2) disciplines, as together they make up a

large portion of the climbing community in the UK (REF Figures). As opposed to the

third discipline (mountaineering), these ways of climbing share a focus on technical

ability and physical strength and aim to minimise the risks of serious injury (Schoffl

et al., 2010).

Climbing has a diverse population of regular participants. It is currently a male

dominated sport of between 70% (Backe et al., 2009) and 83% (Lion et al., 2015)

male participants. The mean age of participants being between 29.2 years (Lion et

al., 2015) and 30.0 years (Backe et al., 2009).

Page ix
The ability of a climber is measured by the standard of climb they can achieve

according to the appropriate interval rating scale (Table1, Table, 2). These are

recognised by international climbing associations and are judged by the individual

difficulty of each movement and the endurance required to complete the climb as a

whole (Watts, 2004). Those climbing at higher grades exhibit increased muscular

strength and endurance of the shoulder and fingers and a high power to body weight

ratio, compared to novice climbers (Giles et al., 2016; Watts, 2004).

Figure 1: A Sport Climbing competition climb. Taken from: UK Climbing, (2016). Available from:
www.ukclimbing.com/news/item/70014/british_lead_and_speed_climbing_championships_2015_report

Page x
Figure 2. A bouldering competition climb. Taken from: UK Climbing, (2017). Available from:
www.ukclimbing.com/news/item/67347/adidas_rockstars_-_international_bouldering_comp

Climbing is a biomechanically complex activity (Watts, 2004; Shea, Shea, and

Meals, 1992). The movement patterns used to ascend a given climb will depend on

the configuration of available holds, and no two climbs will be exactly alike

(Koukoubis et al., 1995). This makes climbing an exceptional activity; in that it

requires using abnormal ranges of movement (ROM), similar to gymnastics (Lion et

al., 2015; Koukoubis et al.,1995; Shea, Shea, and Meals, 1992). The basic

components of upward climbing movements are understood to be concentric; the

upper limb (UL) flexors in conjunction with the lower limb (LL) extensors, propel the

Page xi
climber upwards (Watts, 2004; Koukoubis et al., 1995; Shea, Shea, and Meals,

1992). During certain movements or when the climber loses their purchase on the

holds, muscles will perform strong eccentric contractions, often into abnormal ROM,

which are thought to place a high and repetitive strain on the muscle tendon-unit

(Bahr, 2005; Witvrouw et al., 2004). Whilst climbers utilise both the upper and lower

limbs, an unusually high load is placed on the forearm flexors to maintain a strong

grip on the handholds (Koukoubis et al., 1995). Climbs of a higher grade involve the

use of smaller hand and footholds, more overhanging walls and more dynamic

movement. These factors increase the stress on the flexor muscles of the hand and

forearm, particularly flexor digitorum profundus (FDP) (Balas et al., 2014; Amca et

al., 2012; Koukoubis et al., 1995). The human UL differs from the LL as it has mainly

evolved to perform dextrous tasks and is not adapted to support repetitive heavy

loading in the same way as the LL (Koukoubis et al., 1995). It is therefore not

surprising that an elite climber is more likely develop a forearm muscle injury,

compared to the less able climber (Lion et al., 2015, Jones, Asghar, and Llewellyn,

2008; Rohrbough, Mudge, and Schilling, 2000; Rooks, 1995). Those climbing over

French grade 7b+ are 65.3% more likely to develop an injury than those only able to

climb at 6b-6c+ (Lion et al., 2015).

Muscle injuries have also been described in varied terms in past literature,

sometimes referred to as "pulls", "strains" or "sprains". However, it is widely thought

that these terms refer to the same injury (Muellher-Wolhfahrt et al., 2012). Allowing

this proposal to review past literature with validity.

These injuries are most accurately classified by Muellher-Wohlfahrt et al. (2012) as

functional muscle disorders (FMDs) (Type 1A); the clinical characteristics of this

diagnosis are detailed in Table 3 and Table 4. These classifications will be discussed

Page xii
further in the methodology section. Folkl et al. (2013) completed a large survey of

606 climbers and their recent injury history. 30% had experienced an injury in the

previous 18 months. Functional muscle disorders were found to be responsible for

93% of total climbing injuries, with 81% of these involving the upper limb. After these

injuries, 52% reported the injuries caused them functional limitation and pain for up

to 10 days, 22% and19% had pain for 11-20 days and over 20 days respectively.

The impact of the FMDs on climbers training routines can be serious, when those

injured were asked to quantify this using a score out of 10, the mean score for an

average level of modification was 5.7, based on lost training time and reduced ability.

Functional muscle disorders require rest to rehabilitate properly and for elite athletes,

this is disruptive to normal climbing and training routines (Folk et al., 2013).

Furthermore, sustaining an FMD can lead to chronic symptoms which can impact on

the daily life of a climber (Lion et al., 2015; Folkl et al., 2013; Jones, Asghar, and

Llewellyn, 2008). Overall, previous literature provides strong evidence that FMD

presents an issue for a significant number of elite climbers.

Approximately 550 articles had been published on climbing as of 2016 (Brent et al.,

2016). The biggest challenge when reviewing the literature regarding muscle injury

and elite climbing is the variation in how both areas are described. This occasionally

makes comparison of similar trials difficult. Some authors categorise climbers using

their graded ability (Schrieber et al., 2015; cited in Brent et al., 2016) while inferior

methods categorise based on years of experience, which does not accurately

represent ability (Draper et al., 2009). To address this, Brent et al. (2016),

representing the International Rock Climbing Research Association; published valid

tables (See Table 1 and 2) for how future trials should describe elite climbers.

Page xiii
 Table 1: French grading system and grouping divisions for female climbers. Taken from: Brent et al. (2016)

Table 2. French grading system and grouping divisions for male climbers. Taken from: Brent et al. (2016)

Page xiv
Table 3. Classification of muscle injuries according to Muellher-Wohlfahrt et al. (2012)

Table 4. Sub-category of Overexertion-related muscle disorder. Taken from: Muellher-Wohlfahrt et al. (2012)

Despite climbing increasing its credibility as a mainstream sport, most elite standard

climbers do not receive regular coaching (Brent et al., 2009). Their injury prevention

practices therefore derive mainly from their peers (Lion et al., 2015; Brent et al.,

Page xv
2009). These are generally not evidence based and exhibit large variations in

duration and composition (Lion et al., 2015). Josephsen et al. (2007) surveyed the

injury prevention practices of an elite climbing population; 53% of respondents

reportedly used Static Stretching (SS) techniques before climbing and did not warm

up. Of those who did warm up; 19% did so for <5 minutes, 40% for 10 minutes and

26% for over 10 minutes. The large review of Warm up (WU) strategies by McGowan

et al. (2015) recommends that a WU should last at least 5-15 minutes if a reduction

in injury in the desired outcome. This implies the current strategies used by elite

climbers may be ineffective in achieving their goal of decreasing injury incidence.

Warm up as an activity is a period of preparatory exercise designed to enhance

performance and prevent exercise related injury (Fradkin, Gabbe and Cameron,

2006; McGowan et al., 2015). Like stretching, WU is believed to increase compliance

of the muscle tendon unit and increase its ability to withstand excessive forces

transferred through it. This in turn is believed to make the muscle tendon unit less

susceptible to injury (McCrary et al., 2015). However, fatiguing the muscle through

excess activity makes the muscle more susceptible to injury (McGowan et al., 2015;

Ingham, van Someren, and Howatson, 2010; Fradkin, Gabbe and Cameron, 2006).

Warm up is said to cause physiological changes in the muscle-tendon unit through;

temperature and metabolic mechanisms, including increased metabolism and

elevated oxygen uptake kinetics (McGowan et al., 2015). Although strong evidence

has recommended the inclusion of WU in pre-exercise routines for some time, there

is still debate over which mechanisms are responsible and what elements should be

included in a warm up. These will be discussed further in the literature review.

Page xvi
Static Stretching is defined as movement applied by an external and/or internal force

to increase muscle flexibility and/or joint range of movement (ROM) (McHugh and

Cosgrave, 2009; Whatman, Knappstein and Hume, 2006). Stretching is proposed to

cause a decrease in Musculoltendinous stiffness1 (MTS). This in turn will reduce the

amount of strain on the musculotendinous unit during loaded movement, thereby

reducing the risk of FMD (Herda et al., 2008; Witvrouw et al., 2007; Kubo, Kanehisa,

and Fukunaga, 2002; Taylor et al., 1990; cited in Ryan et., 2015). Contract-Relax

stretching (CRS) includes this stretching force, but immediately beforehand, the

muscle performs a brief (≈5 second) eccentric or isometric contraction against a

resistance applied by the participant or an external force (Kay and Blazevich, 2010;

Kay and Blazevich, 2009a; Kay and Blazevich, 2009b; Morse et al., 2008; cited by

Kay, Husbands-Beasley and Blazevich, 2015). During the muscle contraction;

contractile elements of muscle tissue (muscle belly fibres) are shortened. This

tensions the non-contractile tissues (tendon, perimysium, epimysium, and

endomysium) and decrease in MTS after a prolonged stretch (Kay and Blazevich,

2010; Weerapong Hume and Kolt, 2004). During the subsequent relaxation of the

same muscle; both the contractile and non-contractile elements are elongated

because of the application of external force (Kay, Husbands-Beasley and Blazevich,

2015; Kay and Blazevich, 2010; Weerapong Hume and Kolt, 2004).

The role of stretching in FMD prevention is not fully understood (Jones, Asghar, and

Llewellyn, 2008; Knudson, 2009; Magnusson and Renström, 2006; Witvrouw et al.,

2007). Weerapong, Hume and Kolt (2004) suggested that the acute increases in

ROM and decrease in MTS provided by stretching may only be useful for sports

where a large ROM beyond normal ranges is required, this statement is echoed by
1
The resistance of the muscle and tendon contractile and non-contractile

Page xvii
Knudson, (2009). Stretching may be unhelpful in sports such as running where

normal ROM is not generally exceeded (Fradkin, Gabbe and Cameron, 2006;

Knudson,1999). However, much of past literature has focussed on these running

based sports, which may explain why no clear conclusions have been drawn up to

this point.

It is recognised that this proposal will focus on a select group of individuals. As such,

the conclusions drawn may not be generalizable to a wider population. Static

stretching and CRS are regularly used in clinical practice yet their effects are not fully

understood. Therefore, this proposal may provide insights which are useful in a

clinical setting.

1.1 Research question

__________________________________________

Research on climbing injury up to this point has described the nature and incidence

of climbing injuries well, and has surveyed current preventive measures that climbers

commonly use. Much of the past research has targeted lower limb activities like

running or football. While some positive effects have been observed using these

sports, further research is required to determine whether WU and stretching

modalities have different effects when used in UL activities such as climbing (Jones,

Asghar and Llewellyn, 2008; Magnusson and Renström, 2006; Koukoubis et al.,

1995). Therefore, this proposal will seek to answer the research question;

“In a population of elite climbers, is a combined intervention of CRS+WU more

effective in reducing the incidence of hand and forearm muscle injury than

interventions consisting of combined SS+WU or WU only?”

Page xviii
1.2 Search Strategy
__________________________________________

A comprehensive search of the literature was completed using the Scopus, Medline

and Web of Science databases. For the full search strategy see Appendix 1.

1.3 Research aims and objectives

___________________________________________________

 To examine

2. Literature Review
____________________________________________________________

2.1 Physiological mechanisms for WU

As mentioned in the introduction, warm up is believed to influence muscle and

tendon tissue through several possible mechanisms: With the aim of examining the

evidence supporting these mechanisms and determining how a warm up should be

applied, McGowan et al. (2015) completed a large review article, considering over 30

studies which looked at WU and their underlying physiology. The authors found

mechanisms affecting temperature and oxygen uptake were the most likely to reduce

the strain on muscle and tendon tissue. The authors found good evidence that when

correctly applied, WU could increase the temperature of tissues in the muscle group

being exercised (Racinais and Oksa, 2010; Fisher et al., 1999; Sargeant, 1987;

Bergh and Ekblom,1979 cited by McGowan et al., 2015). In turn it was found that

Page xix
this allowed the muscle to relax more quickly after contraction. This translated to a

reduction in the rate force was transferred through muscle and tendon tissue. Based

on the large body of available evidence, the authors concluded that this was best

achieved through a 9-15 minute period of aerobic exercise at 60-70% of maximum

Oxygen uptake2 (VO2 Max) (Racinais and Oksa, 2010; Fisher et al., 1999; Sargeant,

1987; Bergh and Ekblom,1979 cited by McGowan et al., 2015).

It was also found that if a “priming exercise” was included into WU caused a

significant increase in VO2 max during subsequent exercise (Jones et al., 2008;

Jones et al., 2006; Jones et al., 2003; Burnley et al., 2001; Gerbino, Ward and

Whipp, 1997 cited in McGowan et al., 2015). “Priming exercises” are short periods

of close to maximal activity, e.g. a sprint or a maximum standard climb (McGowan et

al., 2015). 80% of VO2 max was found to be the best intensity for this component.

Intensities below 80% did not elicit an increase in VO2 max. Using a higher intensity

was found to cause muscle fatigue which would impair subsequent muscle

performance (Bailey et al., 2009; cited in McGowan et al., 2015). This mechanism is

thought to improve muscle performance via increases in oxidative enzyme activity

and/or motor unit recruitment. This leads to a decrease in the load placed on

individual muscle fibres, making them less likely to be injured (McGowan et al.,

2015). Together, these factors suggest a plausible and evidence based mechanism

through which WU can reduce injury incidence.

2.2 WU and injury incidence

__________________________________________________________

The systematic review conducted by Fradkin, Gabbe and Cameron (2006) examined

previous randomised controlled trials (RCT) to investigate the effects of pre-exercise

2
Maximum Oxygen uptake is the

Page xx
warm up on injury risk. Five studies were reviewed, included on the basis they used

warm up in their interventions, were conducted on human participants and were

available in the English language. Participants were comprised of runners, American

Football players, and handball players. Methodological quality of research was

scored from 1-11 using the Physiotherapy Evidence Database (PEDro) scale,

(Physiotherapy Evidence Database, 1999). The mean score for this review being 8

(range 7-9). Three of the RCT's showed a statistically significant reduction in total

injuries in their warm up groups compared with controls, two studies showed no

effect. Authors who studied sports involving the UL (Wedderkopp et al., 1999; Olsen

et al., 2005) found that combined injury risk was 5.9 times lower compared with that

of the control groups. From this, the authors concluded that the evidence suggested

warm up to have a significant positive effect on injury incidence, although this may

only apply to sports requiring active ROM beyond normal ranges. Conclusions of this

certainty may be premature given the two RCT's which showed no positive effect

(Pope et al., 2000; Van Mechelen et al., 1993). Although methodological quality was

high across all papers, the variation in sport studied, warm up duration (3-40

minutes), and definition of injury prevent absolute conclusions being drawn. Though

specific data was not provided by the authors of the review, it was remarked that WU

appeared to have the greatest effect on "muscle strain" injuries as opposed to bone

or ligament injury. The two RCT's showing no effects (Pope et al., 2000; Van

Mechelen et al., 1993) studied army recruits and runners respectively, as such their

results may not apply to climbing. Furthermore, Pope et al. (2000) used an

intervention duration of just 3 minutes, which may explain why no positive effects

were observed.

Page xxi
Overall, past research provides adequate evidence that WU should be effective in

reducing muscle injury incidence when applied to sports such as climbing, although

the appropriate duration of WU is likely to be important to achieve the best results.

2.3 Physiological mechanisms for SS and CRS

_____________________________________________________________________

Kay, Husbands-Beasley and Blazevich, (2015) conducted a randomised clinical trial

using seventeen active and healthy adults with the aim of testing the hypothesis that

stretching techniques could influence muscle and tendon mechanics. Nine men and

eight women were randomly allocated to either CRS or SS groups. Firstly, data was

collected on passive ROM (using an isokinetic dynamometer 3) and MTS during

active movement (using a dynamometer and ultrasonography 4). The authors used

this ultrasound imaging to look muscle stiffness separately to tendon stiffness.

Participants then completed a CRS or SS protocol before the measures were

retaken. Stretch durations were __ and __ for CRS and SS respectively. Following

the stretching protocols, the authors demonstrated a statistically significant reduction

in tendon stiffness for CRS (22.1%, P < 0.01), there was also a reduction in the SS

group though this was not statistically significant (1.7% P > 0.05). Both groups

showed statistically significant decreases in muscle stiffness (CRS=20.5% ± 8.9%; P

< 0.01, SS (16.0% ± 12.3%; P < 0.01). A statistically significant improvement in ROM

for both CRS (5.3° ± 4.6°; P < 0.01) and SS (2.6° ± 3.5°; P < 0.01) were also

observed. From these results, in conjunction with data obtained from

ultrasonography, the authors concluded that although both interventions had a

statistically positive impact on MTS. Contract-relax stretching was more effective

3
This is a machine
4

Page xxii
given that it acted on both muscle and tendon materials. The validity of these

conclusion is high, strengthened using objective equipment and data processing

methods to evaluate the intervention (Hicks, 2009). The measurement of MTS during

active rather than passive movement was also necessary to show these

interventions could be effective in preventing injuries sustained during active

exercise. Despite the lack of a control group, this research is of a high

methodological standard, the outcome measures were highly objective and so the

likelihood of human error or bias when collecting data was minimised (Morse et al.,

2008). Procedures for both groups were described adequately enough to be

replicable and showed good control of confounding variables, allowing the any

differences between the two interventions to be observed with validity.

These findings are consistent with several similar trials (Medeiros et al., 2016;

McCrary et al., 2015; Nakamura et al., 2011; Morse et al., 2008; Kubo, Kanehisa,

and Fukunaga, 2002; Kubo, Kanehisa, and Fukunaga, 2001; Handel et al., 1997) 

Regarding stretch intensity; a high-quality electromyography 5 (EMG) trial (Freitas et

al., 2016) recommended a stretch intensity of ≈50% of maximum joint torque to

produce the greatest reductions in MTS.

Summary:

The findings of this research are highly useful for this proposal. In the absence of

conclusive evidence to show CRS and SS prevent FMD, this research provides a

plausible and evidence based justification as to why these interventions could be

effective in protecting muscle-tendon units against injury during climbing.

5
EMG is

Page xxiii
2.4 Stretching and injury incidence
__________________________________________________________________

McHugh and Cosgrave, (2009) conducted a systematic review of the literature to

discern whether SS reduced the incidence of sporting injuries. Seven studies were

examined, four of which reported data on muscle injury incidence. All found

significant decreases in muscle/tendon injuries in their SS intervention groups

compared with controls. In agreement with conclusions made by previous trials

(Knudson, 2009; Fradkin, Gabbe and Cameron, 2006; Weerapong, Hume and Kolt,

2004), the authors concluded that SS could have a positive effect on muscle-tendon

injuries in sports requiring a large ROM. They also emphasised the importance using

the correct stretch duration to achieve the best results. Authors report that

methodological quality was high across the research (six of seven papers were

RCTs). The authors do not state the criteria used to judge the eligibility of the chosen

research, which may threaten the validity of inter-study comparison. However,

enough detail is provided regarding each study. Comparison of this data reveals

sufficient homogeneity between the samples and methods used, so this is not

considered to be significant threat to the validity of the research. One of the four

studies which reported a significant decrease in muscle strains also included WU in

its intervention and not in their control group (Amako et al., 2003). This prevents the

efficacy of SS being examined objectively as any possible positive effects of the

warm up cannot be removed. Although, this trial supports the hypothesis that SS and

WU are most effective when combined. The study showing the greatest decrease in

muscle/tendon injuries, used a sample of yachting crews (Hadala and Barrios, 2009).

Given the similar use of the upper limb between yachting and climbing (Moller,

Larson and Aagaard, 2009), this would appear to indicate that SS may be effective

Page xxiv
when applied to a population of climbers. There was no clear correlation between

stretch duration and decreased injury risk. However, the intervention used by Hadala

and Barrios (2009) featured the longest total stretching time (30 minutes) compared

with the other research included. This supports the conclusion of several other

researchers (Whatman, Knappstein and Hume, 2006; Ryan et al., 2015; Cross and

Worrell, 1993; Taylor et al., 1990) that a sufficient stretch duration is necessary to

observe positive effects on injury incidence.

Summary:

In past literature, researchers have directed much of their focus to running based

sports, requiring joints to move mainly within normal ranges (REFS). Whilst the

quality of this research is often robust, the evidence that SS can prevent FMD’s in

these sports is limited (Weldon and Hill, 2003). Some authors have proposed that

stretching protocols to increase joint ROM and reduce MTS may only be useful for

sports operating outside of normal ROM such climbing and gymnastics. Some high-

quality research has shown positive effects on injury using SS techniques. Not

literature could be found regarding use of CRS to prevent injury. However, using

high quality evidence from previous literature (Kay, Husbands-Beasley and

Blazevich, 2015; Kubo, 2001); it is anticipated that CRS will have a positive impact

on FMD incidence, through the same mechanisms of reducing MTS that apply to SS.

There is good evidence that stretch duration (both individual and total stretch) is

important to reduce FMD (Whatman, Knappstein and Hume, 2006; Ryan et al., 2015;

Cross and Worrell, 1993; Taylor et al., 1990). Amidst the research using running

based sports, the presence of one study looking at a yachting population (Hadala

and Barrios. 2009)(mentioned above), provides some evidence that stretching

Page xxv
interventions may be effective with respect to sports using the UL such as climbing,

given the similar strain on the hand and forearm muscles between these sports

(Moller, Larson and Aagaard, 2009).

2.5 Combined WU with stretching and injury incidence

_____________________________________________________________________

Small and Naughton, (2008) conducted a systematic review into articles which

studied SS in conjunction with an active WU with the aim of preventing exercise

related injuries. Inclusion criteria required research to be an RCT or Clinical

controlled trial (CCT), use amateur or professional sportsmen aged 18-48, have

been published after 1990, and include time loss (from training) as an outcome for

injury severity. Methodology was evaluated using an original scoring method, which

gave a maximum score of 100. Four RCT’s were included (all scoring over 50 points)

in addition to three CCT’s (all scoring below 50).

The authors concluded that given four studies (one RCT and three CCTs) found

statistically significant decreases in “muscle-tendon strains” after their interventions,

a combination of SS and WU were effective to reduce muscle injury but did not

comment on any observable trends in intervention components. However, the

included research exhibits some methodological issues which may threaten the

validity of this conclusion. Blinding of assessors was only used in one trial (Pope et

al., 2000). Furthermore, it was not reported how injury incidence was assessed (self-

report or clinical assessment). It is therefore unclear whether appropriate steps were

taken to ensure reliable and valid measurements. However, the choice to include

Page xxvi
only interventions using SS and excluding stretching techniques such as ballistic

stretching or CRS, allows the effects of SS to be examined in isolation.

Summary of combined WU and stretching;

Greater evidence exists for the combined effects of SS and warm up compared to

their effects separately (REFS). However, the variation with which the two methods

have been combined in the literature makes it difficult to determine the most effective

intervention prescription.

2.6 Summary of Literature

_____________________________________________________________________

While the existing literature would suggest that some relationship exists between

static stretching/warm up and injury incidence, particularly from the reductions seen

in musculo-tendinous injuries (Small and McNaughton, 2008). The obvious limitation

of using the above literature presented is the bias towards LL and running based

sports, meaning that most findings must be extrapolated to be relevant to this

proposal. Even given the large amount of research conducted into the area of LL

pre-exercise warm up and SS, no clear conclusions have been drawn with regard to

how these should be applied.

Research up to this point shows that the effectiveness of pre-exercise methods to

reduce injury

Why CRS should be most effective, then SS then WU.

Page xxvii
References
_____________________________________________________________________

Images:

In your Reference List In your Reference List, the above

example would look like this: University of Salford.

(1970). Artist's impression of Clifford Whitworth Library.

[Drawing] Retrieved from http://usir.salford.ac.uk/10922/

3. Methodology 3110 words (Ref≈505

words)

3.1 Hypothesis
_____________________________________________________________________

Experimental Hypothesis

There will be a greater reduction in the incidence of FMD and reduction in MTS in

participants completing a pre-exercise protocol of a Contract-Relax Stretching and

Warm Up, compared to participants completing a Static Stretching and WU protocol

or WU only.

Null Hypothesis

Page xxviii
There no difference in the incidence of FMD and reduction in MTS in participants

completing a pre-exercise protocol of a Contract-Relax Stretching and Warm Up,

compared to participants completing a Static Stretching and WU protocol or WU only

protocol.

A one-tailed hypothesis has been chosen, indicating that the results will go in a

certain direction (Sims and Wright, 2004). A one tailed hypothesis is preferable to a

two-tailed hypothesis as it allows for a smaller P value. This will reduce the chance

any result obtained will be due to random error (Sim and Wright, 2004). A one tailed

hypothesis has also been chosen due to conclusions of Kay, Husbands-Beasley and

Blazevich, (2015). Showing CRS to have a greater (CRS figures) effect on MTS and

ROM, compared to SS.

3.2 Design
_____________________________________________________________________

A prospective experimental randomized clinical pilot study will be used for this study.

This research aims to draw valid conclusions and make recommendations for the

future. An experimental design has therefore been chosen which can examine the

cause and effect relationships between the independent and dependent variables

(Sim and Wright, 2000). A control group will not be used; this is because this group

would be expected to continue with their previously employed pre-exercise practices.

These practices are far from standardised between climbers Lion et al. (2015).

Therefore, there would be limited validity in comparing data from the control and

intervention groups. Instead, an independent measures method will be adopted

Page xxix
using three groups; SS+WU, CRS+WU, WU only. Warm up will be standard across

the three groups, thus means that the effects of SS and CRS can be isolated and so

described more validly. In addition, all groups will complete a warm up as there is

some evidence to suggest that pre-exercise stretching may be most efficacious

when combined with WU. Given that there are very previous methods studying the

UL specifically (Hadala and Barrios, 2009). Using a pilot design will allow for

methods to be refined for later trials. To negate the effects of participant variables, it

would be ideal to use a matched-subject design. However, there is little possibility a

large enough sample could be found to produce matched triplets (Hicks, 2009).

A single blinding method will be used; participants will be aware of their allocation to

one of the three groups. The researchers taking measurements, will not know the

allocation of each participant. This will attenuate the effects of confirmation bias and

improve the validity of the measurement process (Sim and Wright, 2000). It would be

impossible to blind participants to their allocation to each group as participants are

made aware of the three possible conditions before they give informed consent.

3.3 Randomisation
_____________________________________________________________________

When using an independent groups design, it is necessary to distribute possible

confounding variables evenly between the three groups so that any changes they

cause in the dependent variable are also distributed between the groups (Bailey,

1997). This improves the validity of the conclusions drawn from this methodology,

(Sim and Wright. 2000). Randomisation will occur by drawing folded pieces of paper

Page xxx
each bearing the identification number of a particular participant. This process is

detailed further in Appendix 17.

3.4 Independent and dependent variables

_____________________________________________________________________

Independent Variable

Type of pre-exercise protocol; (Contract-relax stretching + WU), (SS + WU), (WU

only).

Dependent Variables

Incidence of Fatigue-acquired muscle Injury/1000 climbing hours, and MTS of the

flexor muscles of the hand and forearm.

3.5 Population and subject recruitment

_____________________________________________________________________

A two-month recruitment period will be conducted prior to baseline data collection to

gather a sample. Participants will volunteer for the trial after seeing advertisement

posters displayed in their local climbing walls.

The total target sample for this pilot study will be 33 (n=11). If this proposal were not

a pilot study, a larger sample (n >20) would be sought to improve the reliability of

statistical tests when analysing data (Banerjee, 2003). Smaller samples reduce the

likelihood that significant changes in the dependent variable will be observed during

the intervention period (Batterham and Atkinson, 2005; cited in Small and Naughton,

Page xxxi
2008). However, this pilot study seeks to merely gauge the possible relationship

between the stated variables and so a smaller sample is acceptable. In addition,

climbing is not a widely practiced sport and only a small percentage of climbers in

the area, climb at a sufficient standard to meet the inclusion criteria (Brent et al.,

2016). Given the very specific study population chosen for this trial, it is

acknowledged that the conclusions drawn may not be generalizable to athletes in

general or to the public.

Participants will be recruited from six indoor climbing walls in the North West (see

Appendix 2). These are the most popular venues in the area, so it is likely that an

adequate population of eligible participants can be found by surveying within these

places. It would be desirable to gather participants from more regions of the United

Kingdom to obtain a larger, more representative sample of the population of elite

climbers. However, participants in this proposal will be required to attend review

sessions in person and so it is anticipated that widening the search area may

correspond to reduced adherence to the data collection schedule.

Two weeks prior the recruitment process, the climbing venues mentioned will be

contacted via post to seek permission to display posters (Appendix 1) advertising the

upcoming study and providing information on what those interested could expect and

how to apply. The poster will direct attention to a password protected email address

to allow applicants to contact the research team. In their emails, participants are

advised to include their name, gender, address and contact telephone number.

On contacting the research team, responders will receive an information pack

(Appendix) and a consent form (Appendix) by post. Participants who consent will be

contacted within two weeks to be informed of the date of the initial baseline

measurement session.

Page xxxii
The research team will be made up of two qualified Physiotherapists who will assess

FMD incidence and teach the intervention protocols. In addition, two Physiotherapy

Assistants will be used to taken baseline measurements. Staff will be recruited from

a local locum agency. The use of physiotherapy assistants will maximise the cost

effectiveness of the trial, physiotherapists are more expensive to employ but are

more highly trained.

Measurers don’t know the allocation of participants

StaffBlind Role and Involvement

PT1 Non-blind During initial baseline measurement session:
 Teach all the protocols to the three groups,
 Conduct the physiotherapy assessment to assess
incidence of FMD.
 Assess the required intensity of WU, CRS and SS
protocols for each participant.
During subsequent fortnightly reviews:
Training:
 Must be trained in musculoskeletal physiotherapy
assessment skills.
PT2 Non-blind  Teach all the protocols to the three groups,
 Conduct the physiotherapy assessment to assess
incidence of FMD.
Training:
 Must be trained in musculoskeletal physiotherapy
assessment skills.
 Will be trained in how to use electrogoniometer by the
manufacturer.
PTA1 Blind to During the initial baseline measurement session:
group  Take ROM and torque measurements to calculate MTS.
allocation  Take weight, height, body fat percentage,
During subsequent fortnightly reviews:
 Take ROM and torque measurements to calculate MTS.
Training:
 Will be trained in how to use electrogoniometer by the
manufacturer.
PTA2 Blind to During the baseline measurement session:
group  Use electrogoniometer after manufacturer training.
allocation  They will then take ROM and torque measurements to
calculate MTS.
During subsequent fortnightly reviews:
 Take ROM and torque measurements to calculate MTS.
Training:
 Will be trained in how to use electrogoniometer by the

Page xxxiii
 manufacturer.

For each fortnightly re-assessment, participants will attend the University of Liverpool

(UoL) to re-take outcomes for MTS and injury incidence. Information on the total

climbing hours of participants will also be recorded. This may reduce adherence to

the review sessions, however, it is considered important to use a full physiotherapy

assessment to diagnose the occurrence of a FMD. This represents a more valid

measure than a self-report method (Folkl et al., 2013; Rohrnough, Mudge, Schilling,

2000; Sim and Wright, 2000).

3.6 Inclusion and Exclusion criteria

_____________________________________________________________________

Inclusion Criteria Justification

Male or Female climber.
Although currently a male dominated sport
(Lion et al., 2015; Backe et al., 2008), the
popularity of climbing for women is increasing
(The British Mountaineering Council, 2016)
Therefore, female participants will be included,
to increase the relevance of the results of this
proposal for climbing populations in the future.

Within the previous six months,
participant has climbed >1 route of
French grade 8a+ or harder (male
participants) or 7c+ (Female
participants).
Aged >18.
Table 5. Inclusion Criteria
Based on the valid recommendations of Brent
et al. (2016) concerning the criteria to judge
whether a climber is of an elite standard (See
Table 1 and Table 2). In this article, it was also
shown that the answers elite climbers gave
were an accurate representation of what they
could achieve when tested.
Climbers younger than 18 years will not be
included due to additional complications
regarding consent and differences in their
injury incidence rate compared to their elders
(Woollings et al. 2014).

Page xxxiv
Exclusions
Participants with musculoskeletal
pathology currently or within the last
6 months.
Participants with current cardio-
vascular problems. E.g arrhythmias
or atrial fibrillation
Participants unable to read English.
Table 6. Exclusion Criteria
3.8 Procedure
Justification
Current pathology will be indistinguishable from
injuries obtained within the intervention period
and so may cause false positive results to be
observed. Previous injury may increase the
chance of re-injury (REF). If participants with
these characteristics are included they may
reduce the validity of the conclusions of this
proposal
Raising the heart rate of these participants
during the WU protocols has is contraindicated
(REF).
This will prevent them from being able to
complete the intervention protocols from the
written information sheets __APPENDIX.
Page xxxv
Figure__ Procedure flow chart (REPLACE)

Page xxxvi
When the target sample of 33 has been reached, all eligible participants will be

asked to attend a screening and baseline measurement session, held at the UoL

(see below).

Participants will then be notified of their group allocation and taught their given

protocol. They will then be asked to complete their protocols using their written

information (Appendix_, Appendix__) under the supervision of a physiotherapist. The

same researcher will be used to teach all participants. Together, these steps will

ensure the protocols are applied correctly and safely, and that participants will apply

the protocols in the same way when not supervised (Sim and Wright, 2001).

Participants will be instructed to climb with the same frequency and to not alter their

climbing habits during the study. The intervention period will begin immediately after

the baseline data collection session has concluded.

During the intervention period, fortnightly review sessions at the UoL to retake

outcome measures and ensure each protocol is being completed effectively. If

participants are found to be using the wrong technique for their protocol, this will be

noted and the participant will be re-educated. Participant will also be asked to report

their adherence to the treatment protocols so that this can be considered when

forming conclusions (Sim and Wright, 2000).

Participants will be asked to report any pain resulting from climbing/training in the

previous two weeks. If any pain is reported, then patients will undergo a

musculoskeletal physiotherapy assessment (MSKPA) to determine the incidence of

FMD.

It is recognised that adherence to treatment protocols and attendance of fortnightly

review sessions, may be an issue for this proposal. As such, steps have been taken

to maximise adherence: Review sessions will be kept as brief as possible; All

Page xxxvii
required measurements of MTS will be taken for one participant before moving onto

another. Only patients reporting pain will undergo a MSKPA. A MSKPA may take up

to 40 minutes. Therefore, participants will be un-willing to attend subsequent review

sessions if time must be taken to review all 33 participants.

Previous trials have used intervention periods of between two weeks (Andrish et al.,

1974) and two years (Amako et al., 2003). Six months has been chosen as a

compromise. On one hand, a long intervention period is desirable, more data can be

collected on FMD incidence which will strength the reliability of statistical analysis

(Sim and Wright, 2000). On the other hand, participants may be unlikely to adhere to

a trial lasting longer than six months.

At the final review session, participants will be informed that the trial has concluded

and will be given a copy of their data from the trial if requested.

Statistical analysis will then be completed and results presented appropriately.

3.9.1 Baseline Measurement Session

_______________________________________________________________

A MSKPA will be carried out on all participants to exclude those carrying a current

musculoskeletal injury (Appendix__). During this session, measurements of the

following will be taken and recorded in the data collection sheet (appendix):

Measurement Justification Equipment/Outcome

Measure
Incidence of FMD MSKPA using criteria set
out by Mueller-Wohlfahrt
et al. (2012)
Passive ROM;
-Wrist flexion
-1st-5th

Page xxxviii
Metacarpophalangea
l

Resting Heart Rate Pulse Oximeter

(Appendix_)
Age
Gender
Percentage Body

 Passive ROM (Wrist flexion and 1-5th digit metacarpo-phalangeal joint

flexion)

 Resting heart rate, using a pulse oximeter (see Appendix__)

 Height, using a stadiometer (see Appendix__)

 Age

 Gender

 Body fat percentage. Using the Jackson and Pollock, (1985) method (see

appendix_).

 VO2 max. Calculated without a fitness test, using values for maximum heart

rate, resting heart rate and age. (appendix)

3.9.2 Shared protocol goals

_____________________________________________________________________

According to the EMG study by Koukoubis et al. (1995) of the physiology of

elite climbers; interventions to affect forearm injury should target the FDP

muscle in particular, due to its susceptibility to injury. Therefore, skipping has

been chosen for the Aerobic WU task due to its ability to activate this muscle

in addition to its ability to raise the heart rate to the desired levels (Chen and

Lin, 2011). This could not be accomplished through jogging.

Page xxxix
Participants in all groups will complete the same WU protocols as detailed

below. Both SS and CRS protocols will target FDP per the recommendations

of Koukoubis et al. (1995). Two stretches will be included for each group,

designed to target different flexors of the hand and forearm. The first will

require resistance to the palm and so will target the wrist flexors. The second

will require resistance to the fingertips and so will target the long finger flexors

and intrinsic muscles of the hand (Palastanga, Soames and Palastanga,

2011) (Appendix .

Participants are instructed to begin climbing or training within 5 minutes of

completion of their given protocol. This will preserve the validity of the trial as

the effects of the three protocols will be tested in the same way between the

participants in each group (Kay, Husbands-Beasley, and Blazevich, 2015).

ADD WU flow chart

3.9.3 Warm Up protocols

_____________________________________________________________________

For the physiological mechanisms justifications underpinning the WU protocol,

please refer to the Literature Review.

To inform the WU protocol to be completed by all groups; the extensive

review by McGowan et al. (2015) of the literature investigating WU will be the

main source. By looking at how key physiological markers such as MTS and

muscle temperature were influenced by different modalities, they have

provided an evidence based framework for how a WU in an elite climbing

context should be applied to reduce the incidence of FMD’s.

Page xl
The intensity of the Aerobic Activity component should be at 70% of the VO2

max of each participant (McGowan et al., 2015). From calculations; it is

possible to estimate accurately, the required heart rate to achieve this

percentage of VO2 Max (REF). This will be initially examined during the

baseline measurement session; full instructions are available in Appendix 15.

The Priming Activity will consist of four maximal intensity climbs as per the

recommendations of McGowan et al. (2015). Self-reported climbing ability will

be used to gauge the appropriate intensity of the Priming Activity. Draper et

al. (2009) showed that this reliably correlated with the ability of a climber when

tested.

Tailoring both WU components to the ability of each participant will negate the

effects of individual differences in fitness and climbing ability between the

participants and ensure the WU is the same intensity for all (McGowan et

al.,2015). This will aid the validity of conclusions drawn after each intervention

(Sim and Wright, 2001).

To ensure the temperature gains from the WU are not lost during the WU

procedure, time limits should be set for the completion of key steps (see

Figure __) McGowan et al. (2015).

3.9.4 CRS protocols

_____________________________________________________________________

Physiological mechanism for CRS are also mentioned in the Literature

Review.

Based on previous successful trials (Kay, Husbands-Beasley and Blazevich,

2015; Kubo, Kanehisa, and Fukunaga, 2002; Kubo, Kanehisa, and Fukunaga,

Page xli
2001), each Contract-relax stretch will be completed in the following way; a

five second auto-resisted maximal isometric contraction, followed by a 30

second stretch.

The appropriate intensity of each stretch (50% maximum torque) will be

calculated and taught to each participant during baseline assessment and

checked during fortnightly review (Appendix_). Participants will be

unsupervised for most their stretching protocols. Therefore, this method is not

completely reliable and slight variations in stretch intensity are likely between

participants. However, this represents an improvement on all similar trials who

do not attempt to standardise stretch intensity whatsoever (REFS Past

Stretching + injury).

Although Hadala and Barrios, (2009) use a total stretch duration of 30

minutes, Ryan et al. (2015) suggest that a duration of just eight minutes is

required to produce maximal reduction in MTS. The latter recommendation is

a more valid recommendation, generated from a laboratory based study

similar to that of Kay, Husbands-Beasley and Blazevich, (2015). Therefore,

this total duration of eight minutes will be used for both SS and CRS

protocols.

3.9.5 SS protocols
_____________________________________________________________________

As mentioned in the literature review; Hadala and Barrios, (2009) successfully

used a SS protocol, (including a forearm stretch) to decrease muscle-tendon

injuries in a team of elite Yachtsmen. For the SS + WU group, this proposal

will utilise their prescription of duration of stretch (30 for each stretch,

Page xlii
 repeated five times). Their recommendations are consistent with other authors

who have commented on SS duration (Kay, Husbands-Beasley and

Blazevich, 2015; Kubo, Kanehisa, and Fukunaga, 2002; Ryan et al., 2008).

Furthermore, these exercises can be learned under the supervision of a

qualified physiotherapist and then completed unsupervised, using written

instructions and no additional equipment. The written exercise instructions

given to participants (Appendix_) have been devised, based on the available

information from the recommendations of similar successful trials (Cross and

Worrell, 1993; Hadala and Barrios, 2009; Ryan et al., 2015; Taylor et al.,

1990; Whatman, Knappstein and Hume, 2006).

Stretch intensity and total stretch time will be determined using the same

methods as for the CRS protocol.

3.10 Review of outcome measures and data collection

_____________________________________________________________________

According to REFS, a decrease in FMD incidence should be accompanied by a

decrease in MTS if the underlying mechanisms proposed are valid. Therefore, to

protect the validity of conclusions, a measure of MTS will be used. An electro-

goniometer will be this measure. The machine to be used will be NK Hand

Assessment Laboratory. This instrument is superior to a conventional goniometer in

several ways; It is unique in being able to measure the amount of force applied by

the rater during a given ROM measurement, giving values for the torque6 (measured

in Newtons) around a joint, this allows MTS to be calculated (measured by Newton

metre/degrees-1) (Tajali et al., 2016). This method also provides a more reliable

6
Torque is

Page xliii
alternative to manual goniometers due to reductions in random errors and the ability

to calibrate the machine accurately before measurement (Tajali et al., 2016). During

wrist flexion ROM measurements, the NK goniometer exhibits an inter-rater reliability

of 0.95, measured by intra-class correlation coefficient 7. For the same measurement,

qualified physiotherapists were only able to achieve an ICC over 0.9 in 30% of trials,

(LaSanya and Wheeler, 1994). A conventional goniometer would be more

expeditious and portable. However, given its inferior reliability, this method is not

preferable. A more detailed description of how ROM will be measured can be found

in Appendix. The manufacturer of the device will provide advice and training to the

PTs and PTAs involved in this trial.

Incidence of hand or forearm FMD (Type 1A muscle disorders) (See Table 4). will

be measured by a qualified musculoskeletal physiotherapist. As mentioned in the

introduction, this proposal will use the classification system of muscle injuries

devised by Mueller-Wohlfahrt et al. (2012). Unlike previous measures which have

used poorly defined terms such as “strain” or “pull” (REFS), this system of

classification has discrete categories and definitive clinical characteristics for each

classification of injury. This improves the reliability of this measure and marks it as

superior to many definition methods used in the literature (Mueller-Wohlfahrt et al.,

2012). The inter-rater reliability for this system is __.This allows both PTs to be used

to conduct the MSKPA. However, to ensure reliability; all incidences of FMD will be

confirmed by both PTs. Musculoskeletal PTs will already be able to recognise the

clinical signs described in the classification tables and will not require further training.

The examination will include a subjective examination consisting of a “history of the

occurrence, the circumstances, the symptoms and previous problems”, followed by

7
A measure of agreement between two sets of data, a measure of intra-rater or
inter-rater reliability (Sim and Wright, 2000)

Page xliv
an objective examination assessing; palpation, muscle function testing and

comparison to the un-affected side. This data will be recorded using the Subjective,

Objective, Analysis, Plan (SOAP) notes system during the baseline measurement

and review sessions (Appendix 18). All participants will be asked to keep a note of

how many hours of training/climbing they complete during the two weeks between

review sessions. This is necessary to observe any discrepancies between the

groups to preserve the validity of the research (Sim and Wright, 2000). Differences in

time spent climbing/training between groups may affect injury incidence and skew

results (Brent et al., 2016). To compensate for this, injury incidence will be divided by

the total climbing time for each group and multiplied by 1000 to give a figure for FMD

incidence/1000 climbing hours. This a commonly used measure in past literature

(REFS Climbing Injury). Both Outcome measures chosen will provide ratio data.

Hicks, (2009) asserts that this data type is superior to nominal or interval data,

allowing for more precise measurements and use of more sophisticated statistical

analysis.

3.11 Analysis of Data

_____________________________________________________________________

To ensure the randomization process has been successful in distributing

confounding variables (mentioned above) between the three groups, a one-way

analysis of variance test will be used. This is an appropriate and sensitive test to use

for this study design (Sim and Wright, 2000). Confounding variables should be

Page xlv
evenly distributed as this will prevent them from distorting the findings and leading to

unreliable and invalid conclusions (Hicks, 2009).

MTS will be calculated from measures of passive ROM and torque using a fourth

order polynomial regression model, previously described by Nordez, Cornu, and

McNair, (2006).

To determine whether to accept the experimental hypothesis and reject the null

hypothesis; a multivariate multiple linear regression will be used. This is appropriate

as two dependent variables (MTS and FMD incidence/1000 hours) will be used in

this proposal Banerjee, (2003). If any significant difference is observed, the

calculation will be repeated three times, comparing between two groups until all

combinations have been completed. This will discern whether any of the groups are

significantly more effective in reducing MTS and FMD incidence than the others. The

null hypothesis will be rejected if P0.05.

3.12 Ethical Considerations

_____________________________________________________________________

Ethical approval will be sought from the Nation Research Ethics Committee and

research will be conducted in accordance with the Declaration of Helsinki (World

Medical Association, 1967). Participants will give informed consent and be made

aware of their right to withdraw (Appendix_). Participants are protected from physical

harm as they will be told to continue their usual climbing practices. Furthermore,

each of the interventions to be used in the trial are not generally thought to be

harmful to long or short term health (REFs). Participant data will be anonymised by

assigning identification numbers to each participant. Confidential data will only be

Page xlvi
handled by members of the research team and will be stored securely. Physical data

will be kept secure and digital data will be stored on a password protected computer.

References
_____________________________________________________________________

Page xlvii