Sport Health Dec digital

FEATURING

• Making a splash: What four years of injury data revealed about Australia’s elite competitive diving athletes

• Menstrual cycle and mechanical stiffness: what we know so far

• Transforming asthma care in Australia

REGULARS

02

From the Chair

As SMA’s new Board Chair, Professor Anthony Leicht outlines a year of progress marked by updated guidelines, expanding education programs and stronger national collaboration driven by the commitment of members, volunteers and staff who continue to advance safe, inclusive sport.

03

From the CEO

CEO Jamie Crain highlights a standout SMA Conference, the national rollout of the Extreme Heat Guidelines and the introduction of Mental Health First Aid training, all key initiatives ensuring clubs, clinicians and communities are better equipped to support athlete safety and wellbeing across Australia.

Opinions expressed throughout the magazine are the contributors’ own and do not necessarily reflect the views or policy of Sports Medicine Australia (SMA). Members and readers are advised that SMA cannot be held responsible for the accuracy of statements made in advertisements nor the quality of goods or services advertised. All materials copyright. On acceptance of an article for publication, copyright passes to the publisher.

FEATURES

04

Rapid weight changes and injury risk in combat sports: lessons from a 14-month study  Dr Colin Doherty examines the link between rapid weight fluctuations and injury risk in combat sports athletes, offering evidence to guide safer weight management practices and reduce the likelihood of harm during training and competition.

16

Launch of the 2025 Extreme Heat Risk and Response Guidelines and Sports Heat Tool

SMA and the University of Sydney’s Heat and Health Research Centre launches updated Extreme Heat Risk Guidelines and Sports Heat Tool.

11

Cooling breaks in the heat:  Is FIFA’s policy enough for female footballers?

Professor Julien Periard investigates how FIFA’s cooling break policy affects performance and physiological responses in trained female footballers exercising in heat, providing practical insights to support athlete safety and optimise strategies for managing extreme conditions.

Publisher

Sports Medicine Australia  State Netball and Hockey

Centre – Parkville

10 Brens Drive,  Parkville VIC 3052  sma.org.au

ISSN No. 2205-1244  PP No. 226480/00028

Copy Editors

Caitlin Ficken

General Manager,

Membership Development

Sarah Hope

Design/Typesetting

Perry Watson Design

Cover photograph

Getty Images / igoriss

Content photographs

Author supplied; www.gettyimages.com.au

24 Australian Asthma Handbook 2025.

The National Asthma Council presents the 2025 update to the Australian Asthma Handbook, offering the latest evidence-based guidance for asthma management.

19

Menstrual cycle and mechanical stiffness: what we know so far   Michaela McGrath explores how hormonal changes across the menstrual cycle influence mechanical stiffness in female athletes, providing insights that may inform training, injury prevention, and performance strategies. 32

Reflections on the 2025 ASICS SMA Conference

Reflections on the 2025 ASICS SMA Conference – highlights and insights celebrating collaboration, innovation, and the latest in sports medicine practice.

INTERVIEWS

Making a splash: What four years of injury data revealed about Australia’s elite competitive diving athletes.

Ben Currie examines injury patterns in competitive diving, challenging previous assumptions by exploring which injuries occur most often, which cause the most time lost, the overall burden, and whether injuries are more likely during training or competition.

FROM THE CHAIR

Professor Anthony Leicht, Chair, Sports Medicine Australia

Strengthening wellbeing across the sporting community

It is a privilege to write my first message as Board Chair of Sports Medicine Australia. Having attended my first SMA Conference as a postgraduate student many years ago, I never imagined one day serving in this role. I am deeply grateful for the trust of the Board and the support of our staff and members, as well as those who have guided me along the way, including our immediate past Chair, Kay Copeland. Their dedication and leadership reflect the collaborative and generous spirit that defines SMA.

A year of progress and impact

This year has seen SMA continue to strengthen its role as the peak body for sports medicine, sports science and injury prevention. We launched the updated Sports Heat Tool and Extreme Heat Risk and Response Guidelines, released new sports injury fact sheets, and rolled out our national concussion poster campaign, providing practical, evidence-based guidance to more than 30,000 sporting clubs and schools across Australia, and expanded professional development opportunities across disciplines.

Our community came together in Hobart for the 2025 ASICS SMA Conference, a vibrant four days of knowledge-sharing, connection and celebration.

SMA is well positioned to lead this evolution, bridging research, education and practice to enhance health through sport, exercise and physical activity

Building on strong foundations

As we look ahead, we face exciting opportunities and emerging challenges. Technology, athlete wellbeing and inclusion are shaping new approaches to care and performance. SMA is well positioned to lead this evolution, bridging research, education and practice to enhance health through sport, exercise and physical activity. Our focus for the year ahead will be on collaboration and connection, ensuring that SMA continues to support practitioners at every level, from community sport to elite competition.

Thank you

Our Safer Sport Program continues to grow, reaching new university audiences and building collaborations with other associations, national and state sporting organisations to deliver Sports Trainer, First Aid and CPR courses to their members, students and staff. We also launched Mental Health First Aid training, key skills to strengthen all involved in sport and physical activity.

These collective achievements highlight the dedication of our members and committees in advancing safe, inclusive and evidence-informed sport.

Thank you to everyone who contributes to SMA’s success, including our volunteers, committees, partners and staff, and especially our members. Your commitment is the heartbeat of this organisation, and together we will continue to strengthen the profession and the communities we serve.

I look forward to working with you all in the year ahead as we build on SMA’s proud legacy and continue to make sport safer, healthier and more inclusive for every participant.

Professor Anthony Leicht Chair, Sports Medicine Australia

FROM THE CEO

Jamie Crain, Chief Executive Officer, Sports Medicine Australia

Connecting, learning and leading in sports medicine

WITH RECORD ATTENDANCE AT THE 2025 CONFERENCE AND NEW INITIATIVES LIKE MENTAL HEALTH FIRST AID, SMA REMAINS AT THE FOREFRONT OF SPORTS MEDICINE AND ATHLETE CARE.

October saw the sports medicine community come together in spectacular fashion for the 2025 ASICS SMA Conference in Hobart. More than 430 delegates descended on the Apple Isle to share the latest in sports medicine research, clinical practice, workshops, and networking. It was wonderful to see such energy and collaboration across our multidisciplinary community.

Congratulations to all our speakers and presenters for the quality and diversity of their contributions, and a special mention to Dr Andrea Bruder, recipient of the ASICS Medal for Best Paper Overall, for her outstanding research and presentation.

SMA extends sincere thanks to Business Events Tasmania for their invaluable support in hosting this year’s event, and to all members, delegates and sponsors who continue to make this conference the standout gathering in our field each year. Special thanks to ASICS for their enduring contribution to SMA and our field.

The link between physical and mental wellbeing has never been clearer, and we’re committed to supporting both sides of athlete and community health.

ahead of summer. We look forward to seeing this important resource become part of everyday planning and operations for sport across the nation.

Beyond the conference, it has been exciting to see the national launch of the Extreme Heat Risk and Response Guidelines and the accompanying Heat Tool, developed by the University of Sydney in partnership with SMA. This initiative has received widespread attention across the country as community clubs, state sporting organisations and national bodies move quickly to implement proactive heat management plans

Looking ahead, we’re entering another busy season for sports health education and training. In addition to our well-established suite of industryleading courses including Level 1 and 2 Sports Trainer, First Aid and CPR, SMA is proud to introduce Mental Health First Aid. The first course will run in early December, and we expect it to become a cornerstone of our education portfolio. The link between physical and mental wellbeing has never been clearer, and we’re committed to supporting both sides of athlete and community health.

To learn more or register for upcoming courses including Mental Health First Aid, visit sportsmedicineaustralia. com.au/training.

Jamie Crain CEO, Sports Medicine Australia

Rapid weight changes and injury risk in combat sports

lessons from a 14-month study

Why weight cutting matters

Combat sports are weight-category disciplines that include grappling, striking, and mixed-rules formats. To remain competitive, most athletes select a weight class that avoids placing them at a size or strength disadvantage. As a result, rapid weight loss (RWL), commonly referred to as “weight cutting”, has become a widespread and accepted part of preparing for competition.

Athletes typically cut weight in the days or hours before the official weigh-in by restricting food and fluid intake, increasing sweat loss, and using dehydration-focused methods such as saunas or hot baths. These strategies commonly result in a

5–10% reduction in body mass within a week. After the weigh-in, athletes shift their focus to rapid weight gain (RWG), aiming to rehydrate, refuel, and recover before stepping into the ring or cage. Although some athletes regain most of the weight they lost, others enter competition without fully restoring hydration, energy stores, or normal physiological function.

Weight cutting is deeply embedded in combat-sport culture, but its short- and long-term implications for athlete safety remain unclear. Studies from other combat sports suggest that larger or more aggressive weight cuts may be linked with higher injury risk, particularly when recovery is incomplete. However,

the evidence is far from consistent, and very little is known about this issue in sports like mixed martial arts (MMA) and Muay Thai (MT), where weight cutting is often more extreme and athletes typically have a longer recovery window (24–36 hours) between weigh-in and competition.

Another gap in current understanding relates to how much weight athletes actually regain and whether RWG can serve as a practical indicator of how much weight was lost. Many regulatory bodies record RWG at a secondary weigh-in but do not measure RWL directly. It is still unclear whether RWG meaningfully reflects the magnitude of RWL or the quality of an athlete’s recovery.

Taken together, these gaps highlight the need to better understand how rapid weight changes, both loss and regain, relate to injury, particularly in real-world competitive settings. This study aimed to address this by examining RWL, RWG, and their relationship to injury in MMA and MT athletes.

How the study was conducted

This research was carried out over 14 months and involved competitors from 24 sanctioned MMA and MT events in Western Australia. To be included, participants needed to be at least 18 years old, able to complete the questionnaires in English, and competing in an event regulated by the Western Australia Combat Sports

Commission (WACSC). Because the Commission applies the same safety standards to amateurs and professionals, all competitors were analysed as one combined group.

How injury was reported

Athletes completed a health problems questionnaire 5–7 days after their contest and reported any physical complaints that resulted specifically from the contest. The online questionnaire first checked whether athletes had been able to train since competing. If they reported training with a health problem, or not training due to a health problem, they were directed to list all injuries from the contest. If they reported training without health problems or did not train for reasons unrelated to a health problem, they were removed from the analyses.

For the purposes of this study, an “injury” was defined broadly as any physical complaint caused by competing, ranging from soreness and bruising to more serious issues like sprains, fractures, or concussion. Illnesses were excluded.

Because the goal of the study was to understand whether rapid weight changes relate to whether or not an athlete was injured, these responses were grouped simply as injured vs not injured, rather than examining injury types in detail.

How weight cuts and weight regain were measured

To assess weight cutting, athletes completed a short online questionnaire 1-day post-competition and selfreported their body mass seven days and 24 hours before the official weighin. These values were used to calculate RWL-24 hours, and RWL-7 days.

Official weigh-in and secondary weigh-in measurements were provided by the WACSC. The official weighin occurred at least 24 hours before competition, while the secondary weigh-in occurred on the day of the event. The difference between these measurements represented RWG.

From these data, the study calculated:

1. RWL -7 days

2. RWL -24 hours

3. RWG

4. the RWG:RWL ratio (how much weight was regained relative to what was lost)

This approach captures what happens both before and after the weigh-in, two parts of the process that are rarely studied together in MMA or MT research.

Results

Although some athletes regain most of the weight they lost, others enter competition without fully restoring hydration, fuel stores, or physiological function.

A total of 215 responses were collected from 155 athletes competing across 24 MMA and MT events. Because some athletes competed more than once and reported not training due to reasons unrelated to injury, sample sizes differed slightly between analyses.

Table 1 summarises the characteristics of injured and uninjured competitors. Female athletes were generally

Rapid weight changes and injury risk in combat sports

lessons from a 14-month study

older and overwhelmingly represented in MT (90%), whereas the male cohort was more evenly divided between MT and MMA.

How much weight did athletes lose?

When examining body-mass changes, male athletes lost an average of 6.1% of their body mass in the final seven days before weigh-in and 3.0% in the final 24 hours, regaining 5.7% before competing. Female athletes lost slightly less, 4.9% over the week and 2.6% in the final day, but regained 5.8% before stepping into the ring or cage.

Despite these fluctuations, Figure 1 shows that athletes who reported injuries and those who did not exhibited similar RWL and RWG values for both sexes. The smaller sample available for these comparisons (n = 124) may have reduced the statistical power to detect differences.

Male athletes lost an average of 6.1% of their body mass in the final seven days before weigh-in and 3.0% in the final 24 hours, regaining 5.7% before competing. Female athletes lost slightly less, 4.9% over the week and 2.6% in the final day but regained 5.8% before stepping into the ring or cage.

Table 1: Overview of female and male athletes characteristics. Age is presented as median (interquartile range) and remaining variables as count and proportion (%).

Technical knockout/ knockout = TKO/KO, Muay Thai = MT, mixed martial arts = MMA.

Table 2: Logistic regression models examining associations between rapid weight change variables and injury status at 7 days post-competition. Mixed Model 1 [Not injured/ Injured]

Model

Injured]

Model

Injured]

Injured] Predictors

Rapid weight changes and injury risk in combat sports

lessons from a 14-month study

Key regression findings

The regression analyses offered deeper insight (Table 2). Once age was taken into account, two statistically significant associations emerged for male athletes. Each 1% increase in RWL -24 hours was linked with a 1.2-fold increase in the odds of reporting an injury. A similar pattern was observed for RWG, with each 1% increase associated with a 1.1-fold rise in injury likelihood. No rapidweight-change variable predicted injury in female athletes, although the small female sample (n = 37 with complete data) limits firm conclusions. Across all models, older athletes were more likely to report injury, consistent with accumulated training load, prior injury history, and greater exposure time. Rapid weight-change variables collectively explained less than 10% of injury variation, indicating that weight cutting is only one contributor among many.

Can RWG be used to estimate RWL?

We also examined whether RWG could be used to estimate how much weight an athlete actually lost. Figure 2 illustrates the strong correlations between RWL and RWG for both males and females. However, 43–55% of the variation in RWG remained unexplained (R2), meaning that athletes who regained the same amount of weight may have cut very different amounts beforehand. This means RWG should not be used as a standalone indicator of RWL magnitude.

Discussion: interpretating the findings

This study offers new insight into how rapid weight changes relate to injury in real-world competition. The simple comparisons between injured and uninjured athletes (Figure 1) showed no clear group differences in RWL or RWG. However, the regression analyses (Table 2) revealed that male athletes who lose more weight in the final

24 hours before weigh-in are more likely to report injuries one week after competing. RWG appeared to show a similar pattern, but Figure 2 makes it clear that RWG is closely tied to the magnitude of the preceding weight cut. In practical terms, RWG is not acting as an independent risk factor, it is acting as a marker of aggressive RWL.

No significant relationships were found for female athletes. This may reflect genuine sex-specific differences in weight-cutting behaviours or physiology; however, it is more likely explained by the smaller number of female competitors. Research involving female combat athletes remains limited, highlighting the need for future studies that examine hormonal cycles, fluid regulation, sweat responses, and recovery patterns unique to women.

Although rapid weight-change variables were statistically significant in males, their overall explanatory

power was modest. With rapid weight changes accounting for less than 10% of injury variation, it is clear that weight cutting is only one piece of a much larger injury-risk puzzle. Other factors, such as experience level, technical skill, fight dynamics, fatigue, previous injuries, protective equipment, and training load, almost certainly play a greater role. Age also emerged as a consistent predictor of injury across the models, with older athletes reporting more injuries. This is consistent with accumulated wear-and-tear, increased exposure to competition, and a greater history of previous injury.

Importantly, the correlations illustrated in Figure 2 have practical implications. Many combat-sport commissions record RWG but do not track RWL. Our findings show that although RWG reflects RWL to some extent, the relationship is far from perfect. Nearly half of the variation in RWG is unrelated to how much weight was actually lost. Athletes differ substantially in how effectively they rehydrate and refuel, meaning two athletes who gain the same amount of weight may have had dramatically different cutting experiences. For regulators, coaches, and medical staff, this means that relying solely on RWG data can lead to misleading assumptions about an athlete’s weightcutting severity or recovery quality.

Finally, although this study cannot confirm that RWL causes injury, the associations observed in male athletes are consistent with established physiological principles. Even mild dehydration can impair cognitive function, reaction time, coordination, and thermoregulation, all important factors in combat sports. Incomplete restoration of hydration and glycogen stores after weigh-in may leave athletes more vulnerable to fatigue, delayed responses, and suboptimal movement

Each 1% increase in RWL -24 hours was linked with a 1.2-fold increase in the odds of reporting an injury.

patterns during competition. Further research is needed to clarify these mechanisms and to determine whether more moderate, structured weight-management approaches could reduce injury risk.

Practical Implications

The findings reinforce current recommendations to minimise extreme RWL, especially in the final 24 hours before competition. Athletes and coaches should prioritise gradual, long-term weight management strategies rather than relying on late, dehydration-based methods.

Professional guidance from qualified sports dietitians or performance nutritionists can help athletes reduce the magnitude of RWL and support more effective recovery between weigh-in and competition.

Because RWG does not reliably reflect how much weight was lost, regulators and practitioners should be cautious when using RWG data alone to assess the severity of weight cutting or to inform safety decisions. Structured rehydration and refuelling protocols may also help athletes restore essential physiological systems, such as hydration status, plasma volume, and glycogen stores, before entering competition.

Taken together, these findings highlight the need for a more balanced approach to weight management in combat sports.

Rapid weight changes and injury risk in combat sports

lessons from a 14-month study

Reducing reliance on extreme lastminute cuts and promoting safer, evidence-informed practices can help improve athlete welfare and enhance the integrity of competition.

Summary

This study provides new real-world insight into how rapid weight changes relate to injury in mixed martial arts and Muay Thai. Across 24 sanctioned events, most athletes lost 5–10% of body mass before weigh-ins and regained a large proportion before competing, though recovery was often incomplete. While simple comparisons showed no differences between injured and uninjured athletes, regression analyses revealed that male athletes who lost more weight in the final 24 hours, and those who regained more weight after the weigh-in, were more likely to report an injury within seven days.

These associations may reflect physiological responses associated with aggressive weight cutting, although causality cannot be established. No clear patterns were observed in female athletes, likely due to smaller sample sizes. Importantly, rapid weight-change variables explained less than 10% of injury variation, highlighting that weight cutting is only one element within a broader and more complex injury system. RWG was strongly correlated with RWL, but still left nearly half of its variation unexplained, meaning RWG alone cannot reliably indicate how much weight an athlete actually cut.

Together, these findings suggest that while weight cutting may influence injury risk, particularly in the final 24 hours before weighin, it should be managed carefully within a broader athlete-safety framework that emphasises gradual, evidence-based weight management and adequate recovery.

About the Author

Dr Colin Doherty is a Lecturer in Sports and Exercise Science and a Research Coordinator within the Nutrition & Health Innovation Research Institute at Edith Cowan University, Perth. His research focuses on safety and performance in combat sports, with expertise in hydration testing, disordered eating, rapid weight changes, and injury epidemiology. In addition to his academic work, he serves as a performance nutritionist for international fight teams, supporting both gradual and acute weight-management strategies to enhance athlete health and performance. He also works closely with the Western Australian Combat Sports Commission to advance evidenceinformed practice across the sector.

Cooling breaks in the heat

Is FIFA’s policy enough for female footballers?

PROFESSOR JULIEN PÉRIARD, University of

Canberra

Heat stress in female football Football, or soccer, is increasingly being played in hotter conditions due to climate change and the scheduling of major tournaments during summer. This trend is occurring not only in the men’s game, but also in the women’s game. For instance, during the 2019 FIFA Women’s World Cup in France, air temperatures exceeded 38°C, and similar conditions are expected for the 2027 World Cup in Brazil.

Exposure to such heat impairs physical performance, reducing total distance covered and high-intensity running, and increases the risk of exertional heat illness. Research shows that core temperature in female footballers can increase by approximately 2°C during matchplay and exceed 38.5°C in 35°C training conditions. However, data on the severity of the increase in core temperature remain limited. In

other sports like rugby sevens, tennis, and hockey, core temperatures above 39.0°C have been have recorded during play in air temperatures of 30–32°C. Whether female footballers reach or surpass such core temperatures and whether FIFA’s cooling break policy effectively mitigates this rise, remains to be determined.

FIFA cooling break heat policy

To reduce the risk of heat-related illness, FIFA mandates 3-min cooling breaks at the 30th and 75th minutes of play when wet-bulb globe temperature (WBGT) reaches 32°C. These breaks allow players to hydrate and use ice towels. In male players, laboratory simulations have shown that these breaks attenuate the rise in core temperature and heart rate compared to matches without breaks. Extending half-time by 5 min (20 min in total), further enhances this cooling effect.

However, female players differ from males as they are generally lighter, cover less distance during play, and have lower sweating thermosensitivity. While reduced running may lower heat production and storage, potentially decreasing heat illness risk, their lower sweating response may limit evaporative cooling, increasing vulnerability to heat stress. This study therefore aimed to assess the efficacy of FIFA’s cooling break policy and other cooling configurations in reducing core temperature, heart rate, and perceptual strain during simulated football matches in 32°C WBGT conditions in trained females.

Participants and experimental design

Twelve trained female participants (age 25 ± 5 y, height 1.69 ± 0.06 m, body mass 63.0 ± 7.6 kg, peak oxygen uptake [V̇O2peak] 51 ± 5 mL·kg-

Cooling breaks in the heat

1·min-1, maximum heart rate 192 ± 8 beats∙min-1) completed the study. All participants provided self-reported menstrual cycle data, and testing was conducted across different phases of the cycle, with an average of seven days between trials. Trials were completed in a counterbalanced order.

Participants completed an incremental exercise test to determine V̇O2peak before completing five experimental trials (Figure 1). During each trial, a telemetric capsule inserted into the rectum was used to measure core temperature and participants were fitted with a heart rate monitor and four skin temperature sensors to calculate average skin temperature. After entering the environmental chamber, participants completed a 10-min warm-up on a motorised treadmill. This was followed by the football match simulation wherein rectal and skin temperature, heart rate, and thermal comfort and rating of perceived exertion were recorded. Whole-body sweat rate was calculated after each simulation accounting for water ingested, sweat trapped in standardised football ensembles, and time spent exercising.

Match configurations

Each match simulation consisted of a 90-min football-specific intermittent treadmill protocol in 40ºC and 41% relative humidity (WBGT of 32ºC), with an airflow of 2.0 m·s-1. Excluding

the 10-min warm-up (0.82 km), total distance for each experimental trial was 9.5 km, evenly distributed across two 45-min halves (Figure 2). This distance was chosen to reflect the total distance completed by elite female football players.

The five experimental trial configurations included:

ٚ Regular Match (REG): Two uninterrupted 45-min halves, separated by a 15-min half-time in an air-conditioned room (~22°C). Participants consumed 8 mL·kg-1 of 13°C water during half-time.

being identical.

ٚ Break Without Cooling (BRKno-cool): Same half-time protocol as REG, with additional 3-min breaks at the 30th minute of each half. Participants stepped off the treadmill but were not provided with cooling or hydration during the breaks.

ٚ Break With Cooling (BRKcool): Identical to BRKno-cool, but during the 3-min breaks, participants received 5 mL·kg-1 of 13°C water and draped an ice towel (~2.5 kg of crushed ice) over their shoulders.

ٚ Extended Half-Time Without Cooling (ExtHTonly): Half-time extended by 5 min (total 20 min) with water, but no other additional breaks.

ٚ Extended Half-Time With Cooling (ExtHTcool): Combination of the extended half-time and the 3-min cooling breaks in each half. Participants received water at half-time and both water and ice towels during the breaks.

breaks and an extended half-time.

Mean Tsk (°C)

Mean HR (beats·min-1)

[131, 149]

[133, 151]

[132, 150]

[131, 149]

[128, 146]

Data are presented as mean and 95% confidence intervals. Significance is denoted as “>” and was set at P≤0.05. A: regular match (REG), B: 3-min breaks no cooling (BRKno-cool), C: 3-min cooling breaks (BRKcool), D: extended half-time (ExtHTonly), E: 3-min cooling breaks and extended half-time (ExtHTcool).

Physiological responses

The average responses for rectal temperature, skin temperature and heart rate during each trial are presented in Table 1. Final rectal temperature in the ExtHTcool trial was lower than in the REG, BRKno-cool and ExtHTonly trials, but not BRKcool, which was also not different to the REG trial. The change in skin temperature during ExtHTcool was lower than in the REG, BRKno-cool and ExtHTonly trials, but not BRKcool, which was lower than in the REG trial. Final heart rate in the ExtHTcool and BRKcool trials was lower than the BRKno-cool trial, but not REG.

Sweat rate was similar across all trials (1.1 L·h-1) with water consumption being higher in the BRKcool (953 mL) and ExtHTcool (889 mL) trials than in the REG (474 mL), BRKno-cool (459 mL) and ExtHTonly (473 mL) trials. Accordingly, body mass loss was lower in the BRKcool (1.1%) and ExtHTcool (1.1%) trials than in the REG (1.9%), BRKno-cool (1.9%)

and ExtHTonly (1.8%) trials. Of note, percentage of body mass loss was negatively correlated with average rectal temperature (r =-0.26) and heart rate (r =-0.26). Average rating of perceived exertion was lowest in the ExtHTcool trial and thermal comfort lowest in the BRKcool trial (Table 2).

Putting it all together

The physiological responses of female footballers to simulated match play in hot conditions differ from those observed in males. In male players, the FIFA cooling break (BRKcool) was shown to lower average and peak rectal temperature compared to a

Table 2. Mean rating of perceived exertion and thermal comfort during five simulated football matches in 40ºC and 41% relative humidity with and without cooling breaks and an extended half-time. Outcome variable

Data are presented as mean and 95% confidence intervals. Significance is denoted as “>” and was set at P≤0.05. A: regular match (REG), B: 3-min breaks no cooling (BRKno-cool), C: 3-min cooling breaks (BRKcool), D: extended half-time (ExtHTonly), E: 3-min

and extended half-time (ExtHT

Cooling breaks in the heat

Figure 3. Rectal (A) and skin ( B) temperature during the five simulated football matches. Data are means and 95% confidence intervals with individual data points. SHT: start of half time, EHT: end of half time. Hashed lines represent cooling break implementation, where applicable. Significance is denoted as “>” and was set at P≤0.05. A: REG, B:

simulation without breaks (REG). However, this effect was not observed in females (Table 1, Figure 3). The discrepancy likely stems from the higher peak rectal temperature reached in males compared to females (39.1°C vs. 38.7°C) due to differences in metabolic heat production. Indeed, male players reached higher peak running speeds and covered approximately 1 km more total distance, resulting in greater heat generation and a larger potential for ergogenic cooling benefits. Interestingly, core temperature increases during competitive outdoor match play tend to be greater than those observed in laboratory settings for both sexes. This suggests that real-world conditions may amplify the effectiveness of cooling strategies. Nonetheless, further research is needed to evaluate the efficacy of FIFA’s cooling break policy and alternative cooling configurations during actual outdoor matches in the heat.

These findings suggest that integrating a 5-min extension to half-time alongside the existing cooling breaks may be a more effective approach to mitigating heat stress in female football.

Average heart rate in the BRKcool trial did not differ from REG, whereas it was ~3 beats·min-1 lower in the ExtHTcool trial compared to REG (Table 1, Figure 4). Similarly, the rating of perceived exertion was lowest in the ExtHTcool trial compared to all others,

while the BRKcool trial showed no perceptual advantage over the REG trial (Table 2). Notably, both the ExtHTcool and BRKcool trials were associated with reduced thermal discomfort, indicating some perceptual benefit from the cooling interventions. During outdoor match play, the combined reduction in thermal, cardiovascular, and perceptual strain observed in the ExtHTcool trial may help mitigate the adverse effects of environmental heat stress on physical performance. This suggests that integrating an extended half-time with in-play cooling breaks could be an effective strategy to preserve match integrity and lower heat illness risk in female footballers competing in hot conditions.

Sweat rate was consistent across all trials; however, differences in fluid intake led to lower percent body mass loss in the BRKcool and ExtHTcool trials. Participants in these trials consumed approximately 920 mL of water, which

Figure 4. Heart rate during five simulated football matches. Data are means and 95% confidence intervals with individual data points. SHT: start of half time, EHT: end of half time. Hashed lines represent cooling break implementation, where applicable. Significance is denoted as “>” and was set at P≤0.05. A: REG, B: BRKno-cool, C: BRKcool, D:

is higher than the typical intake (570 mL) observed in elite female footballers competing in warm conditions. This discrepancy stems from the study’s prescribed water intake based on body mass, contrasting with the ad libitum drinking commonly practiced in football. These findings highlight the potential for using in-play breaks and half-time periods to implement individualised hydration strategies in female footballers. The importance of hydration is underscored by observed correlations between percent body mass loss and both average heart rate and rectal temperature, with dehydration known to increase physiological strain and impair aerobic performance under heat stress.

Summary

The FIFA cooling break heat policy and extended half-time individually offer minimal physiological or perceptual benefits to females completing a football match simulation in 32°C WBGT. However, when combined, these strategies reduced average and final core temperature, skin temperature, and heart rate, while also improving perceived exertion

About the Author

Professor Julien Périard is Director of the University of Canberra Research Institute for Sport and Exercise, where he leads the Environmental Physiology Research Laboratory. His integrative research examines the physiological mechanisms underpinning health and performance during exercise in extreme environments – heat and altitude – and the adaptations resulting from chronic exposure. His work also explores how therapeutic heat exposure and lifelong physical activity can enhance resilience to rising global temperatures. Professor Périard has collaborated with athletes across multiple disciplines, as well as with national and international sporting organisations including the Australian Institute of Sport, FIFA, World Athletics, and World Triathlon. He currently serves as Associate Editor for the Journal of Science and Medicine in Sport.

and thermal comfort compared to a regular match. These findings suggest that integrating a 5-min extension to half-time alongside the existing cooling breaks may be a more effective approach to mitigating heat

stress in female football. FIFA should consider revising its heat policy to incorporate this combined strategy.

For article references please email info@sma.org.au

Launch of the 2025 Extreme Heat Risk and Response Guidelines and Sports Heat Tool

SMA national media campaign

As hotter and longer summers increasingly affect Australian sport, SMA has taken a major step to support safer participation. The Extreme Heat Risk and Response Guidelines, together with the Sports Heat Tool, have been updated by the University of Sydney’s Heat and Health Research Centre and endorsed by SMA’s Scientific Advisory Committee.

To ensure sporting communities are aware of these important resources, SMA has also undertaken a national media campaign. The focus began in the northern states where higher heat and humidity consistently influence sporting decisions. To date, coverage has included local television on Channel 7 in Northern Queensland, extensive coverage on ABC Radio and other radio networks, helping to spread key messages to clubs, schools and community organisations across the country.

About the Guidelines and Sports Heat Tool

The 2025 Guidelines represent a significant refresh of SMA’s long standing hot weather policy. They incorporate new research and feedback from the sports sector, along with a biophysical heat stress model developed by the University of Sydney. This model considers environmental conditions such as temperature, humidity, solar load and wind, as well as the nature of the sport and typical clothing or protective equipment.

The Guidelines provide sport specific guidance for more than 30 popular Australian sports. They offer clear advice on adjusting activity, improving hydration and shade access, implementing cooling practices and recognising early warning signs of heat related illness.

The Sports Heat Tool converts weather forecasts into an easy to understand Low, Moderate, High or Extreme heat risk rating. Users can select their sport and location and then receive

Updated guidelines and real time tools are helping sport adapt to Australia’s changing climate.

Raising awareness is essential so that heat safety becomes standard practice in every club and school.

hour by hour and seven day forecasts with practical recommendations tailored to the specific code.

Professor Ollie Jay, who led the development of these resources at the University of Sydney says, “We wanted to make sure that we developed something for the community and every Australian could use.”

The online tool can be accessed anywhere, including at the sideline using a phone or tablet.

Supporting sport to adopt safer heat practices

Issuing new resources is only part of the solution. SMA is committed to driving practical uptake across the sports community and supporting organisations to embed these resources into their standard operating procedures and heat policies. The current media activity is helping raise awareness before peak summer activity and encouraging organisations to integrate these tools into their planning.

Key messages include:

ٚ Check the Sports Heat Tool as part of pre event planning

ٚ Modify scheduling, duration and intensity during warmer periods

ٚ Ensure shade, hydration and cooling options are available

ٚ Educate volunteers, coaches and parents about heat illness warning signs

ٚ Make informed decisions to pause, postpone or cancel activity when required

Moving forward

Australian sport has a strong safety culture and these updated resources support that ongoing commitment. With a clearer understanding of local heat risk and straightforward guidance on how to respond, clubs and schools can continue to provide healthy participation opportunities in changing conditions.

The Extreme Heat Risk and Response Guidelines and the Sports Heat Tool are available at sma.org.au.

Menstrual cycle and mechanical stiffness

What we know so far

MICHAELA

MCGRATH, University of Canberra

BETWEEN 2014 AND 2020, ONLY 6% OF ALL SPORTS SCIENCE STUDIES WERE CONDUCTED ON FEMALES, COMPARED TO 31% MALE-ONLY STUDIES.

Female athletes stand to benefit from dedicated sex-specific research that consider the distinctive aspects of our physiology, like the menstrual cycle. In response, a group of researchers came together and initiated the Female Athlete Research Camp (FARC). The FARC 1.0 spanned five weeks, taking place at the Australian Institute of Sport and integrated scientific research with physical training sessions for female athletes, providing a unique platform for longitudinal research.

Central to this investigation is an indicator of athletic performance and

injury risk: lower limb mechanical stiffness. The term ‘stiffness’ is used interchangeably between active and passive measures. Active stiffness refers to the forces produced by muscle contractions acting about a joint, whereas passive stiffness is determined by the mechanical properties of non-contractile tissues such as tendons, ligaments, and joint capsules. Mechanical stiffness is influenced by both active stiffness and passive stiffness.

Mechanical stiffness enables athletes to efficiently convert stored potential energy into kinetic energy

during movement. In effect, there is a theoretical “optimal” amount of mechanical stiffness that allows for peak injury free performance. This is because, when considering the lower limb, as the velocity of a landing task increases, an increase in lower limb mechanical stiffness is desirable to resist collapse of the lower limb and maximise energy return. For example, when an athlete’s foot contacts with the ground during running. However, excessive lower extremity stiffness reduces joint motion, thus increasing the level of shock and peak forces in the joint, which in turn, can increase the risk of bony injury. On the contrary,

Menstrual cycle and mechanical stiffness what

we know so far

insufficient stiffness is associated with excessive joint motion which has been linked to an increased incidence of soft tissue injury.

Previous research has unveiled differences in mechanical stiffness between females and males during landing tasks. These disparities have largely been attributed to differences in body mass. But a key difference between males and females – the menstrual cycle –has not yet been considered.

The menstrual cycle is a vital biological rhythm characterised by significant cyclic fluctuations in hormones, such as oestrogen and progesterone, and typically lasts 28-days (Figure 1). These fluctuations give rise to distinct hormone profiles that allows researchers to group the cycle into 4 phases: (i) Phase-1 or early follicular: low oestrogen and progesterone, (ii) Phase-2 or late follicular: high oestrogen and low progesterone, (iii) Phase-3 or ovulatory: moderate oestrogen and low progesterone, and (iv) Phase-4 or mid-luteal: high levels of both oestrogen and progesterone.

Why should the menstrual cycle be considered as a potential reason

for the disparities seen between mechanical stiffness in males and females? Research has shown that knee joint laxity increases as oestrogen concentrations rise in female athletes. While joint laxity is not the same as mechanical stiffness, it is thought to inversely influence mechanical stiffness. Studies have also shown that peak oestrogen levels correlate with maximal voluntary isometric force of some muscle groups. Since mechanical stiffness is a function of the forces generated by muscles, it’s plausible that menstrual cycle related changes in muscle properties could influence mechanical stiffness.

The aim of this study, therefore, was to examine the effect of fluctuations in sex hormones oestradiol (the most common form of oestrogen in the female body) and progesterone, on mechanical stiffness, during the performance of a drop jump landing task, in female athletes.

Participants and experimental design

This study formed a part of the FARC 1.0, which lasted 16 weeks in total. There was 11-weeks of pre-camp menstrual cycle tracking by members of the larger research team, in the form of a daily online survey, and 5-weeks of in-person training, education, and scientific research sessions. When the athletes weren’t training, they underwent a range of assessments coinciding with Phase-1, -2 and -4 of their menstrual cycle. These other assessments were

completed by members of the larger research team and ranged from venous blood samples to maximum isometric strength. This study specifically quantified mechanical stiffness at these time points, with an extra session at the beginning of the camp to allow for familiarisation.

To be included, participants were classified as Tier 3, or highly trained national level athletes, and had to be available for the full duration of the camp. Athletes were excluded if they were currently pregnant or had a lower limb injury. Twenty-five females, aged between 18 – 29 years, from the National Rugby League (NRL) Indigenous Women’s Academy pathways program, were nominated for participation and provided written informed consent. 24 athletes finished the camp, as one participant withdrew. No exclusion based on menstrual cycle status was implemented, which meant there were 11 naturally cycling athletes, and 13 athletes on various types of hormonal contraception.

To quantify mechanical stiffness, kinematic and kinetic data were collected during a drop jump landing task. Prior to the drop jump, participants were fitted with 28 retroreflective markers on the lower limbs and thorax as defined by the University of Western Australia lower body marker set. A static calibration trial and then functional calibration trials for the hip and knee joints were completed.

Participants then performed three drop jumps off a 30cm box, with the same standardised instructions: “we want you to jump as high as you can and as quickly as you can - pretending the floor is lava”. Participants were asked to keep their hands-on-theirhips, and wear the same shoes, tight fitting sports bra and running shorts for each test session.

During the drop jump protocol, three-dimensional coordinate data were recorded with a 44-camera Vicon motion analysis system (Oxford Metrics Ltd., Oxford, UK), and ground reaction force data were collected using 2 Kistler force plates (Kistler Instrument Corp., Winterthur, Switzerland). All trajectory data were then reconstructed, labelled, filtered, and modelled using Vicon Nexus software (Figure 2). A custom MATLAB script was then used to extract the variables needed to calculate whole body mechanical stiffness (or vertical stiffness), leg mechanical stiffness and joint mechanical stiffness at the hip, knee, and ankle.

2. An example from the analysis software of a. the 3D motion data collected from markers placed on anatomical landmarks of the lower limb and torso and b. the reconstructed segments of the lower limbs

Retrospective confirmation of the menstrual cycle phases was planned using the venous blood samples collected. However, upon this confirmation, it was discovered that Phase-2 was misidentified in five athletes. Therefore, the times when data were collected can only be considered approximations of the phases and thus this specific study instead looked at the relationship between blood hormone levels and mechanical stiffness.

A mixed linear model was used to determine if there was a significant relationship between sex hormone concentration (oestradiol and progesterone) and vertical stiffness, leg stiffness and joint stiffness (of the hip, knee, and ankle). Variables were log transformed based on inspection of the residual analysis to control for leverage as extreme observations can influence the model. Statistical significance was set at p < 0.05.

The findings

A significant, but weak positive relationship was discovered between changes in ankle joint stiffness and both progesterone and oestradiol levels (p = 0.02, p = <0.01, respectively; Figure 3i and j). There was also a significant positive relationship shown between knee joint stiffness and estradiol concentration (p = <0.01; Figure 3h), but no significant relationship was found between knee joint stiffness and rises in progesterone levels (p = 0.75; Figure 3g). Hip joint stiffness was not significantly associated with either progesterone or oestradiol (p = 0.191, p = 0.275, respectively; Figure 3e and f). Leg stiffness was significantly positively associated with elevated oestradiol concentrations (p = <0.01; Figure 3d), but not with progesterone concentration (p = 0.14; Figure 3c). Vertical stiffness was not significantly affected by either progesterone or oestrogen (, p=0.339, p=0.126 respectively; Figure 3a and b).

This study was the first to explore whether female sex hormones, oestradiol and progesterone, correlate with changes in mechanical stiffness in female athletes – both those who use hormonal contraception and those naturally menstruating. The results revealed a positive relationship between oestradiol levels and mechanical stiffness in the ankle, knee, and leg. These findings might have implications for injury risk and performance in female athletes.

Although the study couldn’t precisely analyse mechanical stiffness during specific menstrual phases, it did find a mean change in all measures of stiffness of approximately 12% across approximate phases. What this means for athletic performance or injury risk is not yet clear. Previous studies in this area have used different methods and definitions for mechanical stiffness, making it difficult to agree on what level of

Menstrual cycle and mechanical stiffness

what we know so far

stiffness is truly “optimal” for female NRL athletes. Future research could build on these findings by investigating how these changes in mechanical stiffness may impact injury risk and performance in female athletes.

The study found that increases in oestradiol were associated with higher stiffness in the ankle and knee joints. This may represent the body’s way of maintaining joint stability and counteracting increased joint laxity, which some studies have previously linked to higher oestrogen levels. Oestrogen receptors in ligaments can influence collagen production, which, in turn, affects joint laxity. While this effect has mainly been studied in the knee, similar processes may occur in the ankle.

Previous research has also shown that oestrogen concentration is positively associated with increased muscle strength, in some muscle groups. We speculate that as oestradiol levels rise, the neuromuscular response of a joint may be to increase stiffness in order to counteract increased joint laxity. Although this remains a theory, and future research measuring both joint laxity and mechanical stiffness through the menstrual cycle may better elucidate these findings. Understanding these changes could be key to developing training and injury-prevention strategies tailored to female athletes.

In this study, the strongest effects were observed at the ankle and knee joints. This aligns with earlier research showing that during landing movements, female athletes tend to absorb more force through the ankle and knee rather than the hip. Further, the hip is a complex ball-and-socket joint that moves freely in multiple directions, whereas the ankle and knee are hinge joints that primarily move

Figure 3. The relationship between a. vertical stiffness and progesterone, b. vertical stiffness and oestradiol, c. leg stiffness and progesterone, d. leg stiffness and oestradiol, e. hip joint stiffness and progesterone, f. hip joint stiffness and oestradiol, g. knee joint stiffness and progesterone, h. knee joint stiffness and oestradiol, i. ankle joint stiffness and progesterone and j. ankle joint stiffness and oestradiol. *indicates a significant (p < 0.05) effect of oestradiol level on stiffness. ^indicates a significant (p < 0.05) effect of progesterone level on stiffness. Blue circles represent the observed scores, grey shading represents the 95 % confidence interval, and the black line represents the mean of the observed scores. Note, data are presented as log transformed for visualisation purposes.

Vertical Stiffness (Log e )

Vertical Stiffness (Log e )

Leg Stiffness (Log e )

e. Hip joint stiffness and progesterone

Knee joint stiffness (Log e )

Hip joint stiffness (Log e )

Leg Stiffness (Log e )

f. Hip joint stiffness and estradiol

Hip joint stiffness (Log e )

g. Knee joint stiffness and progesterone

Progesterone (Loge)

Joint Stiffness (Log e ) i. Ankle joint stiffness and progesterone^

Ankle

Progesterone (Loge)

Knee joint stiffness (Log e )

Estradiol (Loge)

h. Knee joint stiffness and estradiol*

Estradiol (Loge)

j. Ankle joint stiffness and estradiol*

Ankle Stiffness (Log e )

Estradiol (Loge)

in the sagittal plane. The drop-jump task used in this study also involved movement primarily in the sagittal plane, so it follows that changes were detected at the ankle and knee joints but not the hip. Future research should consider investigating changes in mechanical stiffness during more complex, sport-specific movements – like cutting or changing direction – to better understand how joints behave in real-world game situations. This is especially relevant for rugby league players, who often perform rapid, multi-directional movements.

While changes in several stiffness measures were linked to oestradiol, only ankle joint stiffness was positively related to changes in progesterone concentration. The exact mechanism behind this relationship remains unclear. Previous research by Shultz and colleagues in 2014, found that progesterone’s effect on joint laxity was inconsistent – sometimes increasing and sometimes decreasing, depending on the individual. This could possibly explain why progesterone seemed to influence the ankle but not the knee in the current study.

The relationship between oestradiol, progesterone, and joint function is complex. More research is needed to understand how these hormones interact throughout the menstrual cycle and how that affects joint stability and injury risk. Future studies would benefit from closely tracking hormone changes across all four phases of the cycle, which could improve the practical application of these findings in training and injury prevention for female athletes.

Limitations and future research

As with any research, there are limitations to consider. This study utilised a sample of convenience of 24 female rugby league players

aged 18–29, which may limit how widely the findings can be applied to other athletes or age groups. This sample size also meant it wasn’t possible to compare athletes who used hormonal contraception with those who did not. Participants were also in the middle of an intense fiveweek training camp, which could have influenced muscle strength and fatigue levels. However, because testing occurred randomly across the menstrual cycle, any training-related effects were likely balanced out.

Another limitation was that interactions between oestradiol and progesterone weren’t analysed, even though these hormones can affect each other. Focusing on them separately allowed for more precise analysis, but it means their combined effects on mechanical stiffness remain unknown.

Additionally, menstrual cycle phases were estimated using self-reported and retrospective hormone confirmation, meaning the timing of hormonal fluctuations wasn’t pinpointed exactly. Future research could improve accuracy by tracking hormones and measuring stiffness more frequently.

Conclusion

This study found that higher oestradiol levels were linked to greater mechanical stiffness in the ankle, knee, and leg, suggesting that the body may adapt to maintain joint stability during hormonal changes. These results could help us better understand how female sex hormones influence performance and injury risk. While rising progesterone concentrations also appeared to correlate with increases in ankle stiffness, its role remains uncertain and may vary between individuals. More studies are needed to confirm these findings, explore changes across the full menstrual cycle, and clarify how hormonal shifts may affect injury risk and performance in female athletes.

For article references please email info@sma.org.au

About the Author

Michaela McGrath is currently completing her PhD at the University of Canberra’s Research Institute for Sport and Exercise. Her undergraduate degree in Physiotherapy (First Class Honours) allows her to integrate clinical insight with research to advance evidence-based practice in the field of human movement control. Her work spans both athletic and general populations, with a particular focus on how factors such as concussion, brain fog, and fatigue influence movement control.

Australian Asthma Handbook 2025

Transforming asthma care in Australia

THE NATIONAL ASTHMA COUNCIL (NAC)

AUSTRALIAN ASTHMA HANDBOOK, THE NATIONAL GUIDELINES FOR HEALTH PROFESSIONALS, WAS UPDATED IN SEPTEMBER 2025, AND REPRESENTS A SHIFT IN HOW ASTHMA IS MANAGED IN AUSTRALIA.

The update involved a major revision of clinical guidance and a complete redesign of the website, led by a multidisciplinary network of leading expert primary care and specialist contributors on the NAC Guidelines Committee.

Asthma in Australia

Asthma is a chronic inflammatory condition that affects 2.8 million, or one in 9 Australians. Despite asthma deaths almost halving from 964 deaths in 1989 when the NAC was established, to 478 deaths in 2024, there is still a long way to go to reduce these tragic preventable deaths.

In Australia, 34% of total burden of disease is due to respiratory conditions and an estimated 1.8 million (65% people) with asthma also have one or more other chronic conditions.

The NAC is committed to providing practical guidance for health professionals and advocating for the need to improve asthma care. This includes adopting the guidance in the handbook for use by multidisciplinary health professionals who are responsible for patients that might have respiratory and other co-morbidities.

In Australia, the common approach to asthma management was starting patients with mild asthma on short acting beta2 agonist (SABA) (blue puffer), to take as needed. This treats the asthma symptoms, but it does not treat the underlying cause of asthma - inflammation of the airways.

Many patients are also managing their own asthma with blue puffers that they can buy over the counter at the pharmacy. This encourages risky over-reliance on SABA which can mean asthma is poorly controlled, leading to a higher risk of severe asthma attacks.

What’s new in the Australian Asthma Handbook

The NAC’s updated Australian Asthma Handbook guidelines outline a shift in how asthma is managed by:

ٚ encouraging health professionals to stop prescribing or advising treatment with as-needed SABA alone to manage asthma in adults and adolescents

ٚ recommending anti-inflammatory reliever (AIR) only therapy and maintenance-and-reliever therapy (MART) for adults and adolescents (aged over 12 years)

ٚ providing recommendations for patients with severe asthma that cannot be controlled with inhaled corticosteroid (ICS)-

containing treatments

ٚ offering guidance on pathways for timelier and more streamlined referral of patients to monoclonal antibody therapies.

These changes in recommendations mean that people with asthma, including mild asthma, need to see their GP for an asthma review, to ensure they are on the right treatment and that they have an up-to-date asthma action plan.

Anti-inflammatory reliever only therapy

The updated Australian Asthma Handbook guidelines encourage health professionals to avoid prescribing or advising treatment with as-needed SABA alone to manage asthma symptoms in adults and adolescents. Inhaled corticosteroids (ICS) are indicated for all adults and adolescents with asthma.

Starting adults and adolescents instead on anti-inflammatory relievers is recommended because they include the quick action of a long-acting beta2agonist formoterol which gives relief from symptoms, and a lowdose corticosteroid which works by reducing inflammation in the lungs that causes an asthma attack.

Treatment for adults and adolescents should be started with inhaled lowdose budesonide-formoterol, taken as needed when symptoms occur. Lowdose budesonide-formoterol taken as needed has been shown to reduce the risk of severe exacerbations requiring oral corticosteroids (OCS) compared with taking SABA as needed.

As-needed SABA alone is inadequate treatment for asthma in adults or adolescents and is associated with a higher risk of severe asthma exacerbations, compared with low dose ICS-containing treatment. SABA over-reliance is associated with increased risk of asthma-related death.

Maintenance and reliever therapy

In the updated Australian Asthma Handbook, maintenance and reliever therapy (MART), low-dose ICS–

formoterol (budesonide-formoterol, beclometasone-formoterol), is used as both a reliever medication and maintenance treatment, if needed. Maintenance treatment is generally not necessary for patients with infrequent symptoms and no specific indications for maintenance ICS treatment. Lowdose MART results in lower average OCS dose than daily maintenance ICS.

MART has been shown to reduce risk of severe asthma exacerbations requiring OCS, hospitalisation or emergency department presentations.

The updated guidelines advise that low or medium-dose MART should be commenced for patients with frequent symptoms, recent severe exacerbations or known risk factors for severe exacerbations.

Role for sports trainers, sports medicine and allied health professionals

Optimal treatment of asthma reduces the frequency and severity of exercise-induced symptoms which can be common in people with asthma. Exercise-induced bronchoconstriction is characterised by coughing, dyspnoea, wheezing, or chest tightness after exercise. Frequent exercise-induced symptoms may indicate poor asthma control.

Health professionals working in sports medicine have an important role to play in ensuring optimal asthma management so that people with asthma can live full and active lives. This includes:

ٚ identifying patients that may have sub-optimal control of asthma or who may not have been formally diagnosed with asthma

ٚ diagnosing patients with spirometry and other diagnostic tests*

ٚ referring patients for further medical or specialist treatment

ٚ educating patients on how to recognise and manage symptoms during exercise and that they don’t need to avoid exercise

ٚ ensuring patients are having regular asthma reviews with their GP and that they have an

up-to-date asthma action plan

ٚ knowing how to recognise an asthma emergency and how to administer asthma first aid.

In light of the updated Australian Asthma Handbook guidelines, health professionals working in sports medicine should ensure they:

ٚ understand the shift away from SABA to anti-inflammatory relieveronly therapy or maintenanceand-reliever therapy (MART) for adults and adolescents

ٚ understand the risks of SABA over-reliance, acknowledging that these medications are available over the counter

ٚ take the opportunity to speak to patients with asthma to understand their current treatment or management plan

ٚ ensure they ask if patients have an up-to-date asthma action plan with explicit instructions on prevention and management of exercise-induced symptoms

ٚ ensure that patients see their GP regularly for asthma control checkups and refer them back to their GP to review their current management plan

ٚ ensure patients know how to use their medications correctly, to demonstrate the use of medications and to refer patients to the NAC’s comprehensive inhaler video library.

About the Australian Asthma Handbook

The National Asthma Council Australia (NAC) is the national authority on asthma knowledge, leading the improvement of asthma care and management in Australia.

Australian Asthma Handbook updates are developed and approved the NAC’s Guidelines Committee which comprises respiratory specialists, primary health care nurses, general practitioners and pharmacists. The Australian Asthma Handbook also include updated recommendations for paediatric asthma management.

Learn more: asthmahandbook.org.au nationalasthma.org.au

*(conducted by sports medicine GPs)

Quality footwearchildren’s for growing feet

ASICS has established itself as a leading manufacturer of children’s athletic footwear, combining innovative technology with thoughtful design to support young, growing feet. A strong commitment to quality and performance is evident in every aspect of the ASICS children’s shoe collection, making the brand a trusted choice for parents and referring practitioners.

The ASICS Kids footwear range includes running shoes, school shoe options, and sports shoes for netball, football, tennis, track and field, basketball, and field sports. At the heart of the ASICS kids’ range is a focus on superior design and advanced technology. ASICS utilises quality midsole foams and signature GEL™ technology to deliver essential cushioning for active children who spend their days running, jumping, and playing.

Durability is a key focus in the design of ASICS kids’ shoes, with robust materials such as solid rubber outsoles engineered to withstand the demands of daily wear. Additional features like the rubber toe cap, toe rubber stitching, and medial outsole wrap-up are specifically designed to extend the life of each pair.

From toddler sizes through preschool to grade school, every shoe is tailored to meet the unique needs of children at different developmental stages. Kids-specific

lasts are used for each age bracket to ensure proportional fit across various age groups. This attention to anatomical detail extends to the overall construction of the footwear, promoting healthy foot development while maintaining comfort and style.

Aaron Robertson, podiatrist and PhD candidate explains, “Given the differences in children’s foot structure, clinically it is important that children’s footwear correctly matches their foot shape and facilitates their function.”

Importantly, ASICS kids’ shoes do not incorporate hollowed or cupped midsoles design elements. For children, the priority is consistent support, durability, and comfort for growing feet. A full-bodied midsole provides even cushioning and structural integrity, which is essential for healthy foot development and everyday wear.

“With the variation in children’s foot mobility and stiffness observed in clinical practice, it is important to ensure the torsional resistance and ability of the footwear to absorb impact forces is individually prescribed”, emphasizes Aaron.

Whether for everyday use or athletic activities, ASICS kids’ shoes offer the support and comfort necessary for healthy foot growth while delivering the durability expected from a premium footwear brand. The combination of innovative technology and design, and a commitment to quality continues to position ASICS as a leading choice in children’s footwear.

Making a splash

What four years of injury data revealed about Australia’s elite competitive diving athletes.

Why most diving injuries happen out of the spotlight – and what that means for athlete health.

When we think of Olympic diving, we picture the perfect take-off, clean aerial movements, and that rip entry without a hint of splash. But for most athletes, the real story happens in the countless hours of training, unseen moments in the dryland training sheds, the high-performance gyms, and the swimming pools across the country.

Until recently, little has been known about what injuries occur in competitive diving athletes. Past research has focused almost exclusively on short competition periods such as the Olympics or World Championships. However, these events capture only a small fraction of an athlete’s

exposure, with the knowledge of what injuries divers report across a season remaining a blind spot in sports medicine. The result? A skewed picture that underestimated the true injury risk of the sport.

That’s the gap a new four-year observational study by Currie and colleagues set out to close. With the authors aiming to answer the following questions: what type of injuries actually occur most commonly (incidence), what injuries keep athletes out the longest (burden), what injuries have the highest cost of injury (incidence x burden), and where do injuries most commonly occur – in training or during competition.

The study

Sixty-three elite divers, made up of 43 women and 20 men, from Diving Australia’s national program were monitored by sports and exercise physicians and physiotherapists. Every medical attention injury, whether it resulted in missed training or not, was recorded in a centralised athlete management system (AMS).

The scope of this study was unprecedented for this sport: four years of continuous data, capturing more than 65,000 athlete trainingdays of exposure. This allowed the research team to map out the when, where, and how injuries occur – across both training and competition environments.

Each season, between 70 and 85 per cent of divers reported an injury, with almost twothirds resulting in time lost from training or competition. Almost 90 per cent of all injuries occurred during training

What they found

There is often a misnomer that diving is safer and that athletes transitioning from sports such as gymnastics and acrobatics are less likely to get injured in diving. The findings of this study turned these long-held assumptions on their head.

Injuries were common – and they mostly happened in training, NOT competition.

Each season, between 70 and 85 per cent of divers reported an injury, with almost two-thirds resulting in time lost from training or competition. Almost 90 per cent of all injuries occurred during training, most often during pool sessions rather than in the gym or dryland training environments. Only a tiny fraction (around 2 per cent) happened during competition itself.

The data also showed no difference in injury rates between male and female divers, suggesting that prevention strategies can be implemented universally across the sport.

A high cost to pay

The high forces associated with takeoff, and water entry, particularly from the 10-metre platform, place enormous load on the diving athlete. Platform divers experienced a slightly higher rate of injury overall than springboard divers. According to body location, the lumbar spine, wrist and hand, and shoulder were the most frequently injured areas. Springboard divers were more prone to lower limb bone stress injuries.

Perhaps most striking was the injury burden: on average, athletes spent the equivalent of 90 days per year

unavailable due to injury. Lumbar spine and wrist injuries proved to carry the highest injury burden by body location, underscoring the cumulative toll of repetitive diving loads.

What’s happening beneath the surface

The study sheds new light on how diving injuries occur. The “take-off” and “water entry” phases of the dive were the reported mechanism of injury for more than half of all reported injuries. These phases of the dive are responsible for both the generation of large forces (take-off phase), and the absorption (water-entry) of force.

A diver hits the water at close to 60 kilometres per hour, before experiencing a rapid deceleration that places torque through the upper limbs and spine. During competition, male divers will compete 6 dives per round, and female divers will compete 5 dives per round of competition – completing up to 3 rounds of competition dives at each event. However, in training, divers will complete hundreds of dives per week, and repeated exposure to these high forces can lead to overuse conditions such as impingement syndromes, tendinopathies, and bone stress related injuries.

The research also identified concussions, though rare, as an emerging concern in the sport. from This highlights the need for clear recognition and management protocols in aquatic environments.

Why this matters

These findings challenge the longstanding perception that diving is a relatively low-risk sport. In reality, injuries are frequent, often substantial, and mostly occur within the daily training environment.

Making a splash

For high performance staff working in diving that insight is critical. Injury prevention strategies must be embedded within training, not just implemented around competition. Examples of this include:

ٚ Targeted strength and conditioning programs to support lumbar spine and shoulder strength.

ٚ Monitoring of symptoms related to lumbar spine and lower limb bone stress in springboard divers.

ٚ Explore the use of protective wrist supports and/or modified load progressions to reduce upper limb trauma.

ٚ Continue high-quality injury surveillance to capture even minor “niggles” before they become time-loss injuries.

A platform for the future

By taking a long-term, traininginclusive view of injury surveillance, this research offers a clearer picture of the true demands of springboard and platform diving on a divers health. It highlights the need for sport-specific strategies that account for the demands of training – and not just competition.

As the authors note, understanding

The scope of this study was unprecedented for this sport: four years of continuous data, capturing more than 65,000 athlete trainingdays of exposure.

when and why injuries occur is the first step towards keeping divers healthy, available, and performing at their best.

The next challenge for high performance staff, inclusive of coaches and support staff, is to translate these insights into prevention strategies –turning the data that was captured at pools around the country, into healthier, longer, and more fulfilling careers for Australia’s elite athletes.

For article references please email info@sma.org.au

About the Author

Ben is an APA titled sports and exercise physiotherapist who has current affiliations with Queensland Cricket, Tennis Australia, and Water Polo Australia. Ben completed his PhD in performance health in Australian diving athletes and now works as a researcher with Griffith University, investigating clinical concussion profiles in female athletes, whilst consulting at the Clem Jones Centre in Brisbane.

For elite performance

Reflections on the ASICS SMA Conference

HELD ON HOBART’S PICTURESQUE WATERFRONT FROM 29 OCTOBER TO 1 NOVEMBER, THE 2025 ASICS SMA CONFERENCE BROUGHT TOGETHER NATIONAL AND INTERNATIONAL EXPERTS ACROSS SPORTS MEDICINE, PHYSIOTHERAPY, PODIATRY, AND EXERCISE SCIENCE. OVER THE FOUR DAYS, ATTENDEES ENGAGED WITH THE LATEST RESEARCH AND PRACTICAL APPROACHES IN ATHLETE CARE AND PERFORMANCE.

This year’s program featured an exceptional line-up of keynote and invited speakers, including Refshauge Lecturer Professor Nick Brown, Professor Michael Rathleff, Dr Edna King, Associate Professor Michelle Smith, Dr Carly McKay, Professor Ollie Jay and Professor Silvia Blemker. Their presentations set the tone for a program that balanced scientific depth with clinical relevance.

The program covered a wide range of topics, including concussion and athlete brain health, injury prevention in adolescents, management of a range of injuries including hamstring strains, ACL rehabilitation, and ankle injuries, and strategies for managing heat stress in both elite and community sport.

A notable focus this year was on the female athlete. Several workshops and symposia explored the specific challenges faced by women and girls in sport. These sessions included researcher, practitioner, and athlete perspectives on issues such as multilevel approaches to injury prevention, gaps in existing research on gender-specific factors, and strategies designed for sporting associations to better support women from preconception through to parenthood while keeping them engaged in the sport they love.

Jackie Whittaker: “I think one of the biggest highlights for me has been just the focus on female women and girl athletes. There’s been so many sessions and just such incredible work that’s being done by everybody, and it just feels like it’s timely and coincides with just all the success and growth that we’ve seen in the women’s games. So just super excited by all that.”

The global scope of the Conference was a recurring theme for many attendees. The opportunity to learn from international experts and share experiences across borders enriched discussions and highlighted the universal goal of advancing athlete health and performance.

Dr Ryan Moran from the University of Alabama: “Coming from the United States, it’s very interesting to see all the different research that’s going on around Australia and also learning from other professions. Obviously, in the United States, our main area of sports rehabilitation and injury prevention is with the profession athletic training, learning

2025 Conference

more about the physiotherapists and their role, especially when it comes to concussion management and concussion rehabilitation, has been very critical to understanding some of the areas that we can improve upon, but then also some of the information that I can then take back to the United States to say, here’s what’s going on around the world, here’s some of the things that we can learn from, but also here’s opportunities for us to collaborate internationally with different organizations, different universities and different faculty.”

The ASICS SMA Conference has always been more than an academic meeting, it’s a chance to reconnect

with colleagues, exchange ideas and celebrate achievements. Delegates enjoyed the opportunity to collaborate, network and be inspired by the sense of community that defines our profession.

Peter Dornan AM: “I always enjoy the social aspect of these meetings. The networking is terrific, particularly in these days when you don’t meet face to face too often. Of course, the scientific aspect is always up to date, and it really is my compass for the whole year, and I relate that to every aspect of what I do as a physio”.

Congratulations to all award recipients recognised at the 2025 ASICS SMA Conference across Clinical Sports Medicine, Sports and Exercise Science, Sports Injury Prevention, and Physical Activity and Health Promotion. Special

We extend sincere thanks to ASICS Oceania for their ongoing partnership and support as major sponsor. We also thank Strapit, JSAMS, JSAMS Plus, our trade exhibitors and session sponsors, whose contributions enrich the delegate experience and help make this event a success.

A special acknowledgement goes to Conference Committee CoChairs A/Prof Kathryn Mills and A/Prof Ryan Timmins and the Conference Committee for their hard work in delivering a seamless program, engaging sessions, and valuable networking opportunities. Delegates now look forward to continuing these conversations and reconnecting next year in Brisbane.

Physician Focus

David Hughes Interview

During your time as AIS Medical Director, what stands out as the most complex medical or governance issue you had to navigate?

One of the things I really enjoy about my role at AIS is that complex, difficult, or novel issues tend to land on my desk. I am very fortunate to have, both at the AIS and externally, a strong network of colleagues in the sports sector who have skills different from my own, and who I can call upon to help problem-solve.

One of the most topical and challenging issues we are assessing at the moment is mandatory genetic sex testing for female athletes in some international sports. While the goal of fairness in the female category is a priority, there are broader ethical considerations in this matter. Medical tests should only be conducted when there is a clear medical indication, a potential health benefit for the athlete, and preservation of athlete autonomy. That is, the athlete should be making the decision of their own free will and from an informed position, where all the ramifications of the test have been explained. Highly motivated athletes, however, can feel pressured to comply to remain eligible to compete. In almost all cases for Australian athletes, there is no medical indication for the genetic sex testing. While unexpected results are uncommon, they do occur in Australian cohorts. An unexpected result could have serious consequences for an athlete’s sporting career, fertility, or general health.

While some medical practitioners are uncomfortable facilitating these tests, athletes will often find a way to get the tests done anyway. This creates a responsibility for leadership in high-performance sport to minimize harm by ensuring that athletes receive education, counselling, and informed consent so that any testing is conducted as ethically and safely as possible.

Other challenges in my role have included urgent medical situations,

such as being called on at very short notice to assist athletes who have suffered serious injuries while competing abroad. These situations can be confronting, given the logistics and high stakes, but they are also incredibly rewarding when you can provide support to athletes and their families during a time of critical need. My role frequently includes a mix of medical, ethical, and pragmatic decision-making, which I find challenging but rewarding.

As Olympic Team Doctor, how did you adapt your approach when confronted with Zika in Rio versus Covid-19 in Tokyo?

Both situations were unique but shared common features. With Zika in Rio, the main concern was the potential impact on unborn children, a confronting prospect for female athletes of child-bearing age. There was very little information available, and a lot of uncertainty and misinformation circulating, so clear communication and education were essential. We relied on expert advice from Brazilian authorities, who assured us that risk of mosquito born disease was low at that time of year, but we still had to adopt a precautionary approach. There were multiple conspiracy theories suggesting a deliberate cover-up and that the Olympics were unsafe. Some individuals chose to withdraw from the Games due to concerns for their health or family planning, and those decisions had to be respected. Importantly, among the more than 400,000 people who travelled to Brazil for Rio 2016, there were no cases of Zika exported, highlighting that the risks, while concerning, were effectively managed.

Covid-19 in Tokyo was on a completely different scale: a global pandemic causing border closures, quarantines, serious health risks and a postponed Olympics. We were responsible for more than 1,000 Australian athletes and support staff, requiring high-tech, in-house PCR testing, strict protocols, and constant monitoring. A key part of our approach was surveying the medical and performance team about their confidence and concerns, then addressing those issues in real time. During the Tokyo Games we had daily challenges, including athletes who had direct contact with confirmed cases. In high-risk exposure cases we had to test athletes, isolate where needed, and keep training/competition on track. Thanks to these systems, there were no Covid cases in the Australian Olympic team during the Games.

The best solutions are rarely developed in isolation but require input from diverse perspectives across the sporting ecosystem.

In both Rio and Tokyo, the common thread was meticulous planning, clear and frequent communication, and prioritising athlete and staff welfare in all planning decisions. The challenges were stressful and unpredictable but ensuring the team had accurate, timely information and the reassurance to make informed decisions, maintained team unity and delivered positive health outcomes.

Physician Focus

David Hughes Interview

How has your long association with Sports Medicine Australia shaped your career, thinking, or clinical leadership?

SMA has been instrumental in fostering multidisciplinary collaboration across sport and exercise medicine. Through work on position statements and other initiatives, SMA provides a platform for medical practitioners, allied health professionals, and performance staff to come together and tackle complex, high-stakes issues in sport. These projects encourage sharing of expertise, rigorous debate, and development of practical, evidence-based guidance that can be implemented across different levels of sport.

What makes SMA particularly valuable is its reach, from elite highperformance environments to grassroots and community sport. This ensures that advice is not only consistent but also accessible to all athletes, coaches, and support staff, regardless of their resources or geographic location. Over my 30year membership, I have witnessed firsthand how cross-disciplinary collaboration leads to better outcomes: it improves athlete care, strengthens team performance, and helps create safer, more informed sporting communities. SMA reminds

us that the best solutions are rarely developed in isolation but require input from diverse perspectives across the sporting ecosystem.

Your work with SMA on concussion statements has shaped national practice. What gaps in athlete care drove that collaboration?

The main gaps in athlete care were around simplicity of message, consistency of message and accessibility of contemporary, evidence-based advice. Too often, athletes, parents, coaches, and

volunteers received conflicting guidance from different organisations, which created confusion and made it difficult to know what information to trust. There was also variation between sports, levels of competition, and jurisdictions, which meant that not all athletes had equal access to reliable information or safe management practices.

The 2024 Concussion and Brain Health Position Statement addressed these gaps by providing an evidencebased framework, and the first ever international, intergovernmental alignment between Australia, New Zealand, and the UK. The position statement delivers clear, practical, and accessible information for all sports participants, regardless of their location, resources, or level of play. The statement ensures consistency in recognition and management of concussion, promotes conservative, athlete-first decision-making, and supports clinicians by providing clear protocols to follow. Importantly, it also helps protect athletes from undue pressure to return to play prematurely, offering a standardised approach that reduces variation in care and reinforces best practice across the sporting landscape.

Looking ahead, where do you see the biggest unmet needs in athlete health and medical oversight in Australia’s highperformance system?

One of the biggest unmet needs is protecting athletes from misinformation and oversimplified narratives. One example of this is the complex and evolving environment related to brain health and chronic traumatic encephalopathy (CTE). There is no argument that the brain must be protected from potential long-term consequences of repeated head trauma (RHT). Brain health however is nuanced, and media coverage often reduces the issue to a simple cause-and-effect narrative that does not reflect the scientific evidence. For instance, CTE is often presented as an inevitable consequence of repeated head impacts, but the relationship between RHT, neuropathological changes and brain health symptoms is complex, variable, and influenced by multiple factors. Oversimplified reporting can create unnecessary fear or misperceptions among athletes, their families, and the wider community.

Australian sport will need ongoing education and advocacy, constant

interpretation of complex evidence and communication of advice in a manner that athletes, coaches, and support staff can understand and act upon. Providing clear, accessible guidance while acknowledging uncertainties is a responsibility of leadership.

Organizations such as SMA, AIS, ACSEP and APA have a critical role in maintaining this balance: ensuring athletes have access to the latest evidence, are empowered to make informed decisions, and are protected from undue pressure or harm, while promoting consistent, multidisciplinary, evidence-based approaches across all levels of sport.

Out of all the sports you’re immersed in, what’s your personal favourite?

If you asked me 20 years ago, I would have said rugby union. I played rugby at school and university and absolutely loved it. These days, my sporting interests are much broader. I am fascinated by the variety of skills in Olympic and Paralympic sports. Personally, I love going for a run or a row; it keeps me moving, clears my head, and reminds me how fortunate I am to still be able to enjoy being active. Fitness is great, but for me, it’s just as much about keeping sane!

People who shape SMA Ebonie Rio

Can you share your journey from starting out in physiotherapy to your current role in research and sport?

My path into physiotherapy wasn’t direct, after high school I completed a Bachelor of Applied Science at Deakin because I didn’t initially get into physio. I enjoyed the course, did well, and considered honours but instead reapplied for physio and got into La Trobe.

After graduating, I worked at Monash Hospital and additionally part time in private practice before landing what was, a dream job as physiotherapist for The Lion King in Melbourne and then in Shanghai tour. Working with performers pushed me into areas I didn’t know well yet, including posterior ankle pain, dance specific overload, and gymnastics style loading, which led me to seek out people like Sue Mayes at The Australian Ballet and Wendy Braybon at the VIS. Those early connections shaped the rest of my career.

When the Shanghai contract ended, I considered touring with the production in South Africa, but I had also applied for the AIS postgraduate scholar role. I was fortunate to be selected, so I moved to Canberra in

2006. That year was formative, being surrounded by leaders like Craig Purdam, Andrea Moseler, Peter Blanch, Tony Ward and Ivan Hooper, which accelerated my learning dramatically.

Craig offered me a job in AIS Physiotherpay department (dream job #2) at the end of that program, conditional on completing my masters degree. I did the coursework remotely through La Trobe and completed clinical placements with Sue Mayes and Wendy Braybon. In 2010 I returned to The Australian Ballet and the Victorian Institute of Sport, and

I still say I haven’t decided what I want to be when I grow up, and that’s probably true!

other than short breaks, I’ve been at both ever since (dream jobs #3!).

After several years balancing work across ballet and the VIS, I felt the pull toward research again. I had stayed friends with Jill Cook after doing honours with her, and we started talking about a PhD. I eventually committed full time, stepped away from ballet temporarily, kept my role at the VIS, and completed my PhD on tendinopathy.

Today, I still have footings in all three worlds: clinical practice at the ballet, high performance sport at the VIS, and research and teaching at La Trobe. I still say I haven’t decided what I want to be when I grow up, and that’s probably true!

What first sparked your interest in tendinopathy, and how has your understanding of it evolved?

I first worked with Jill Cook during my honours, though my project wasn’t in

tendinopathy. My real interest emerged at the AIS while treating basketball athletes. Tendons were the area where I felt we had the most unanswered questions, especially in season.

With bone stress or muscle strains, you can give reasonably accurate timeframes. Tendons, particularly in competition can be tricky with schedules that are outside your control. I wanted to understand how to keep athletes playing safely, not just how to rehab them in the off season. That gap in the evidence base is what drew me in.

Around that time, Jill and Craig Purdam were teaching widely and were generous in inviting me and Sean Docking to teach alongside them. Being exposed to that level of clinical and research discussion accelerated my understanding enormously.

Over time, I’ve come to appreciate tendinopathy as a condition where

the science, the load profile, the athlete’s context, and the competition demands all collide. That complexity is what keeps me interested today.

Working at the intersection of research and practice can be challenging. What’s been key to translating evidence into real world outcomes?

The key for me is that everything has to be clinically useful. If I can’t apply it, I don’t research it.

A lot of my research originates from simple, practical questions that come up. For example: what exercise reduces tendon pain without compromising strength or performance? I ran pilot testing specifically to understand how much rest is needed between repetitions so that tendons feel better without leaving the athlete fatigued or unable to jump. If the tendon improves but the athlete can’t perform, the intervention is pointless and perhaps detrimental.

People who shape SMA

Ebonie Rio

Clinically, every athlete you see is an n=1 experiment. You have a hypothesis, you test it, you adjust. That mindset aligns perfectly with research; you’re just applying more structure and rigour. Even though the work uses different parts of the brain, the overlap is huge. One makes the other better.

How has your involvement with SMA shaped your career and contributed to your work in sports medicine?

SMA has played a massive role. I’ve been a continuous member since I was a physiotherapy student, and I’m now on the board of directors. I’ve cochaired the SMA Conference with Luke Kelly and have had the chance to see the organisation from many angles.

What SMA does exceptionally well is create community. It supports students and young researchers in a way that genuinely makes a difference. I’ve been fortunate to win

Clinically, every athlete you see is an n=1 experiment. You have a hypothesis, you test it, you adjust.

several SMA awards, from my early career presentation at the 2004 SMA Conference in Alice Springs to two more awards during my PhD. Those awards helped me attend conferences, build networks, and share my research.

But beyond the practical benefits, it’s the multidisciplinary nature that matters. When you get physios, sports scientists, doctors, podiatrists, researchers, and students in the same room, the ideas are better. SMA fosters that diversity; it is one of its biggest strengths.

Looking back, what have been the standout moments or milestones in your career so far?

There have been so many highlights along the way. The SMA awards definitely stand out, not just for the financial support but for the peer review process, and how competitive they are, which makes them extra meaningful. A highlight was receiving the ECR award in Thailand with Joe my husband and my baby Cooper being there in 2013. Seeing my students win awards or research grants is equally if not more rewarding; those moments are genuinely special.

Clinically, receiving the Australian Sports Medal for my contribution to sport after the Commonwealth Games was a major milestone. Being nominated as one of the top 200 female speakers globally, an entirely peer curated list, was another huge

honour because it’s recognition from colleagues and general public.

Finishing my PhD and receiving the award for Best Thesis in the Faculty of Medicine, Nursing and Health Sciences and being awarded Victorian Fresh Scientist in the same year was definitely a stand out. This wasn’t long after having my second baby Oli.

Completing my PhD while having two babies has been hugely significant. They’re now 10 and 12, absolutely sport mad, and seeing them grow alongside my career has been one of the most important milestones of all.

Be ready for the conversations that change lives.

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Strengthen your practice with evidencebased mental health training. Scan the QR code to view our upcoming courses. SMA Members receive 15% off all Sports Trainer courses. Recognise the Signs Respond with Confidence Support Through Crisis Become an Accredited MHFAider

Sports and Exercise Medicine in Brazil

DR. FABIO PERALTA MATHIAS MD

BRAZIL IS HUGE AND HAS A NUMEROUS POPULATION: 213 MILLION INHABITANTS IN AN AREA OF MORE THAN 8,500,000 SQUARE KILOMETERS. ITS VAST CONTINENTAL DIMENSIONS, RICH CULTURAL DIVERSITY, AND SIGNIFICANT SOCIOECONOMIC DISPARITIES PROFOUNDLY INFLUENCE THE LANDSCAPE OF EXERCISE AND SPORTS MEDICINE WITHIN THE COUNTRY. THIS UNIQUE CONTEXT SHAPES BOTH THE HISTORICAL DEVELOPMENT AND THE CURRENT STATUS OF THE FIELD, PRESENTING BOTH CHALLENGES AND OPPORTUNITIES FOR GROWTH AND ACCESSIBILITY.

History

Sports medicine in Brazil traces its origins to the early 20th century, evolving alongside the emergence of organized sports and physical education. The increasing popularity of football, athletics, and military physical training spurred medical professionals to delve into performance optimization, injury prevention, and rehabilitation. Initially, general physicians and orthopedists offered informal support to athletes.

Brazil’s notable participation in global events, particularly the 1952 Helsinki and 1960 Rome Olympics, underscored the critical need for structured medical support for athletes. In the same period, the country achieved remarkable results in other sports, specifically (but not limited to) three Soccer World Cups in twelve years. This led to the establishment of early institutional initiatives, including the formation of multidisciplinary care teams within state-run sports centers.

A key development in the field was the establishment of the Brazilian Society of Sports Medicine in 1962, at first named as The Brazilian Federation of Sports Medicine (Federação Brasileira de Medicina Desportiva). This organization consolidated national efforts to formalize the specialty and foster scientific exchange, playing a crucial role in advocating for the official recognition of sports medicine as a distinct medical specialty.

Interestingly, the organization was renamed in 1993, becoming the Brazilian Society of Exercise and Sports Medicine, reflecting the expansion of the specialty’s scope of action beyond sports practice and professional sports, encompassing exercise medicine as a preventive and therapeutic tool for a series of diseases.

It is also important to highlight Paralympic sports, in which Brazil has been gaining prominence in recent

and Brazil had continuous growth in the medal table, reaching prominent positions in editions such as Athens 2004, Beijing 2008, and London 2012.

A key development in the field was the establishment of the Brazilian Society of Sports Medicine in 1962, at first named as The Brazilian Federation of Sports Medicine.

years, being an important branch of exercise and sports medicine in the country. Adapted sport arrived in Brazil with wheelchair basketball in 1958, leading to the founding of the Optimism Club. The country’s debut in the Paralympic Games occurred in 1972, winning its first medal in 1976. From 1988 onwards, the Paralympic Games began to be held in the same host city as the Olympic Games. In 1995, the Brazilian Paralympic Committee (CPB) was founded, which boosted the development and visibility of adapted sport in the country, with the Agnelo/Piva Law in 2001 guaranteeing the transfer of funds. There was a restructuring of sports organization, focusing on modalities instead of types of disability,

The opportunity to host the Rio 2016 Paralympic Games resulted in the construction of the Brazilian Paralympic Training Center in São Paulo, a fundamental legacy for adapted sport, inaugurated in 2016. The Paralympic movement continued to grow, with the expansion of representation in winter sports and the development of social and high-performance projects. Brazil achieved expressive victories in World Championships and Parapan American Games, consolidating its position as a protagonist in the Paralympic scene. In 2020, the CPB suspended activities due to the Covid-19 pandemic, but resumed work, and the Tokyo 2020 Paralympic Games (held in 2021) marked the country’s 100th gold medal and its best historical participation to date. In 2024, in Paris, Brazil broke all medal records, winning 89 in total, including 25 gold, and achieving an unprecedented 5th position in the mega-event.

Despite these achievements, most services and organized institutions are concentrated in the Southern and Southeastern regions of the country. That is due to the complexity of the country itself, with remarkable inequalities of structure among different regions, socially

Sports and Exercise Medicine in Brazil

and economically. The historical and geographical disparities of development in Brazil generate this and other kinds of distortion.

Growth and Institutional Development

The importance of sport for the country includes the creation of the Ministry of Sport in Brazil as the Extraordinary Ministry of Sport in 1995, with Pelé as the first minister. It was renamed the Ministry of Sport and Tourism and, in 2003, became the Ministry of Sport, an agency with autonomy and under the responsibility of the Executive Branch. Subsequently, in 2019, it was extinguished and became the Special Secretariat for Sport, linked to the Ministry of Citizenship, but it was recreated in 2023. This institutional strengthening opens paths for greater action by Exercise and Sports Medicine in the country.

The late 20th century marked a period of progressive institutionalization for sports medicine in Brazil. Leading universities such as the University of São Paulo (USP), Universidade de Caxias do Sul (UCS) and Federal University of São Paulo (UNIFESP) established research groups and postgraduate programs focusing on exercise physiology, rehabilitation, and

musculoskeletal health. Currently, there are eight recognized residency programs in Exercise and Sports Medicine linked to universities, the vast majority in the Southeastern region, with only one in the Northeastern region of the country. There are many private postgraduate programs, also concentrated in the southern region of Brazil.

In 2000, Sports Medicine received official recognition as a distinct medical specialty from the Brazilian Medical Association (AMB) and the Federal Council of Medicine (CFM). This recognition significantly boosted the development of residency programs, postgraduation courses and specialist certification exams, aligning Brazilian training with international standards.

Over the subsequent decades, Brazil expanded its academic and clinical infrastructure. Sports medicine clinics began to emerge within teaching hospitals and public health institutions. Major sporting events hosted in the country — including the 2007 Pan American Games, 2014 FIFA World Cup, and the 2016 Olympic Games in Rio — served as accelerators, attracting visibility, investment, and technology transfer to the field. Today, Brazil boasts over 2,000 certified

sports medicine specialists and numerous training centers integrated with university hospitals, private clinics, and rehabilitation networks.

In addition, the growth of the specialty also occurs in scientific production: Brazil contributes with many relevant and growing publications in recent decades, having consistently ranked among the top ten countries with the highest production in the area (in 2025, it currently occupies 11th place). Many Brazilian specialists participate in international organizations, contributing to important decisions, both from a scientific and institutional point of view.

Training and Specialisation

Prior to 2000, physicians aspiring to specialize in sports medicine in Brazil typically completed a residency in clinical or surgical specialties—most commonly orthopedics, physical medicine and rehabilitation, internal medicine, or cardiology—followed by a fellowship or postgraduate program in sports medicine. Alternatively, doctors with substantial experience and academic credentials could obtain certification through the SBMEE’s rigorous board examination process.

Currently, residency programs are available across some Brazilian states, concentrated mostly on the Southeastern region, allowing newly graduated physicians to directly enter these specialized training pathways. These residency programs emphasize a multidisciplinary approach, covering:

ٚ Musculoskeletal and joint injuries

ٚ Exercise physiology and cardiopulmonary evaluation

ٚ Nutrition and supplementation

ٚ Sports psychology and mental performance

ٚ Doping prevention and anti-doping science

ٚ Return-to-play protocols and athlete monitoring

Trainees gain exposure to diverse populations, ranging from elite Olympic athletes to individuals with chronic conditions who utilize exercise as therapy. Clinical immersion in team-based care, including field coverage for competitive events, forms a fundamental component of the training process. There is also a growing trend towards academic qualification, with an increasing number of sports physicians pursuing Master’s and PhDs in fields such as biomechanics, epidemiology, and public health. Brazil’s scientific output in this area is also growing, contributing to global knowledge and best practices.

The Current Landscape and Workforce

Brazil’s sports medicine landscape mirrors its continental scale and socioeconomic diversity. Specialists operate in a wide array of settings:

High-performance sports:

National and state teams, Olympic/ ParaOlympic committees, and professional clubs employ physicians year-round, particularly in popular sports like football (soccer), volleyball, and mixed martial arts.

Rehabilitation and orthopedics: Many sports physicians work in multidisciplinary clinics focused on injury recovery, post-surgical rehabilitation, and musculoskeletal optimization.

Exercise as medicine: In recent years, there has been a notable shift towards prescribing physical activity for the prevention and management of non-communicable diseases. Sports medicine physicians are key players in programs addressing obesity, diabetes, cardiovascular disease, and depression, often in communities with high rates of these conditions due to socioeconomic factors.

Public and private health systems: While access to sports medicine services varies across regions, public initiatives are increasingly - although at a very slow pace - integrating these services into SUS (Brazil’s public health system), particularly in universityaffiliated hospitals and state-run rehabilitation centers, aiming to bridge the gap in underserved areas.

Despite these advancements, challenges persist. Access to specialized training remains concentrated in urban centers, leading to a low density of specialists in rural and underserved areas, as also in the northern region of the country, which counts currently with only one residency program. Furthermore, the specialty competes with other established fields (such as orthopedics and cardiology) for leadership in domains like injury prevention and athlete care. This scenario has evolved over the last decades, since the approach assumes

a more collaborative feature.

Another challenging issue is bringing exercise and sports medicine with its preventive and therapeutic potential to the general population. Sedentary lifestyles and diseases resulting from them generate enormous costs for public health. Brazil has a healthcare system structured for universal access, despite many weaknesses. There is potential to use this system and use sport as an instrument to strengthen citizenship, through education and health.

Nevertheless, Brazil stands out in Latin America as a leading reference in sports and exercise medicine. It continues to gain international recognition, actively participates in global networks, and fosters a vibrant scientific community, all while striving to address the unique health needs of its diverse population through the lens of exercise and sports medicine.

About the Author

Dr. Fabio Peralta Mathias, MD is a Sports and Exercise medicine specialist based in Rio de Janeiro, Brazil. He is the current President of the Rio de Janeiro Sports and Exercise Medicine Society (SMEERJ) for the 2025/2026 term. With extensive experience in cardiopulmonary rehabilitation and multidisciplinary care, he also acts as a health system manager and medical educator. He coordinates initiatives integrating exercise into chronic disease care, combining clinical practice with teaching, research, and international collaboration.

Rose Mercieca Sports Trainer Spotlight

What initially motivated you to pursue a career in sports medicine and sports training, and how did that lead to the creation of Complete First Aid?

My career began with a strong passion for helping people move and perform at their best in all aspects of life. I started in remedial massage and injury rehabilitation, working hands on with athletes across a range of sports, as well as in a clinic setting with everyday clients. Over time, I realised that while I was doing important work in treatment and recovery, there was a real need for quality, sport-specific first aid education and event support, something that bridged the gap between healthcare and performance.

I started out working in a physiotherapy clinic and with athletes through the sports training company Complete Body Dynamics, which I eventually took over. That experience gave me a deep understanding of how injuries occur, how to prevent them, and the importance of proper management. During COVID, I upskilled by completing my trainer and assessor certification, which allowed me to step into the field of education. This transition also shaped the evolution of my business from Complete Body Dynamics into Complete First Aid. The rebrand reflected our growth, offering a complete service to the general and sporting community, encompassing treatment, prevention, emergency care, and education.

At its core, it’s about empowering others with the skills and confidence to act when it matters most, whether working with elite athletes, community clubs, or everyday situations.

Tell us about your company and the work you do.

Complete First Aid operates across New South Wales, working with local clubs, schools, and event organisers. Our work falls into three main areas:

First Aid Training: We deliver accredited first aid and CPR courses designed to be engaging, handson, and relevant to real-world environments. We are also a mobile provider, so we bring the training to clubs, schools, and the workplace.

Participants do the theory online first, then come to the practical session ready to ask questions and learn in the exact environment they’ll be using their skills. That makes the learning much more practical and less intimidating.

Event First Aid Coverage: We provide professional first aid services at sporting events, school carnivals, and community festivals, managing everything from minor injuries to complex emergencies. Our trainers come from sport and health backgrounds, so we understand what it’s like to be on the sidelines and bring that practical experience to every situation. Our mission is simple: to make first aid practical, approachable, and meaningful for athletes, clubs, and communities at every level.

Sports

Support and Mentoring:

We mentor and train sports trainers and club volunteers, helping build grassroots capacity in injury knowledge and management. I always aim to help my trainers grow so they can reach their career goals, whether that’s working with community teams or pursuing elite opportunities.

You’re also a presenter for SMA’s Sports Trainer courses. What do you enjoy most about that role, and what do you see as the biggest value these courses offer participants? I absolutely love seeing people grow in confidence, particularly those who have never worked in sport before. Watching

Knowing your skills is one thing, but having the courage to act, communicate clearly with others on scene, and maintain composure under pressure is what truly makes a difference.

participants progress from being hesitant to fully capable of managing on-field situations is incredibly rewarding. There’s nothing better than seeing someone leave a course saying, “I can do this. I know how to help now.”

SMA courses are special because they combine evidence-based sports medicine principles with very practical, hands on learning. Participants don’t just walk away with a certificate; they gain real-world skills. That includes strapping techniques, injury assessment and management, and learning how to communicate effectively with coaches, medical staff, and athletes under pressure. I often see allied health students in these

courses who have all the theoretical knowledge in the world but haven’t yet had the chance to put it into practice. Watching them translate theory into action, build confidence, and step up in real scenarios is incredibly fulfilling.

For me, the biggest value lies in empowerment. These courses give people the confidence and knowledge to make a tangible difference, whether it’s improving an athlete’s performance, ensuring safety on game day, or supporting recovery from injury. It’s not just about the technical skills; it’s about inspiring people to step up, take responsibility, and feel capable in situations they might have found intimidating before.

You’ve taught and mentored many trainers through SMA courses. What are the most common areas you see new trainers needing to develop, and how do you help them bridge that gap?

The main areas are practical confidence, communication, and situational awareness. Learning theory is one thing but responding to an injury in real time with adrenaline, crowds, and pressure is completely different.

I focus on realistic simulations and mentorship. I encourage trainers to communicate clearly with coaches, players, and medical staff, and to plan for what could go wrong. Another challenge is understanding the broader context of sports medicine; pre-game preparation, recovery, and return-toplay protocols. By exposing trainees to real sporting environments and encouraging reflection, they start connecting the dots between first aid, performance, and athlete wellbeing.

I also share real-life experiences, like being first on scene at a severe motorbike accident, to illustrate the importance of confidence, quick thinking, and empathy in highpressure situations. In that instance, there were two nurses behind me who didn’t have the necessary equipment, and I had all the gear in my car. We did everything we could in a critical situation, but unfortunately, the rider didn’t survive. Even though we couldn’t change the outcome entirely, being

Rose Mercieca

present and providing immediate care made a real difference by giving the person comfort and support in a frightening moment. Experiences like this show new trainers that knowing your skills is one thing, but having the courage to act, communicate clearly with others on scene, and maintain composure under pressure is what truly makes a difference. These are the lessons I aim to pass on, so trainees feel empowered to respond effectively, even when outcomes are uncertain.

What advice would you give to trainers who want to strengthen their skills, gain more experience, or move into leadership or education roles in the field?

Take every opportunity you can to get hands on experience. Volunteer at club games, school carnivals or community events, even if it costs you more in petrol than what you get paid. Every environment teaches you something new and helps build the confidence you need to step up when it matters.

For example, working with the Parramatta Eels development squad as the head trainer for the under 18s team

didn’t pay much, but it was invaluable. It gave me the chance to demonstrate my skills, build strong professional relationships and eventually led to work with the club’s elite A Grade team. Those early opportunities, even the unpaid ones, were stepping stones that shaped my career and opened doors I wouldn’t have imagined at the time.

I would also encourage Sports Trainers to keep learning. Sports medicine and first aid are always evolving, so staying current with new practices, equipment and safety standards is essential. But technical knowledge is only part of the equation. Your soft skills such as communication, organisation and mentoring are just as important, especially if you’re aiming for leadership or education roles. Find mentors who can guide you, and don’t be afraid to put yourself forward for opportunities, whether that’s presenting, coordinating event coverage, or mentoring new trainers.

Above all, remember why we do this: to keep people safe, supported and performing at their best. Passion, dedication, and perseverance will open doors, sometimes in ways you

can’t anticipate. The work can be hard, and you have to earn your stripes, but every challenge is worth it when you see the impact you can make.

You recently welcomed your first child. How are you navigating being a new mum in the context of running a business and finalising your studies?

It hasn’t been easy, but it’s been incredibly rewarding. I’m currently on maternity leave from my remedial massage role, but I haven’t taken leave from my business. I’m fortunate to have an amazing team who manage our event coverage so I can focus on the organisational side from home. I’m also in the final stages of completing my Master’s in Exercise Physiology, so life is busy, but I wouldn’t change it.

It’s been a big adjustment, but I’m learning as I go. I’ve had to become more organised and realistic about what I can do in a day. Some days the business takes priority; other days, family does. Having help from my partner and family has been essential and I couldn’t do it without them. It’s made me appreciate how important flexibility is, especially for women working in sport or running their own business.

Balancing work, study, and motherhood isn’t perfect. There’s mum guilt, late nights, and rescheduling, but the flexibility, purpose, and ability to help people make it all worthwhile. Looking ahead, I plan to merge my exercise physiology work with my business and eventually open a holistic care clinic; a one-stop shop for EP, physio, sports training, and allied health to provide complete, integrated support for the community and athletes alike.

Take your practice beyond the clinic and onto the field.

Sports Trainer Level 1

Sports Trainer education for allied health professionals seeking broader impact, stronger community presence, and meaningful professional growth.

Front-line clinical exposure

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Advance your practice beyond the clinic. Scan the QR code to view upcoming courses. SMA Members recieve 15% off all Sports Trainer courses.