Jul 31, 2017
A Step Ahead
Dr. Robin Queen, Keith Doolan, Frederick Purnell, and Dr. Shawn Arent

By utilizing blood-based biomarker testing, the performance teams at Virginia Tech and Rutgers University are out in front when it comes to maximizing athlete potential and minimizing injury risk.

This article first appeared in the July/August 2017 issue of Training & Conditioning.

At the highest levels of competition, the use of sport science to assess athletes and provide feedback is here to stay. Sports teams at Virginia Tech and Rutgers University are no strangers to these efforts, with both schools investing in sport science to maximize athlete performance and health.

In the past, we used numerous strategies to achieve these goals, including tracking player load with GPS devices; testing strength, power, and agility; and evaluating movement mechanics. Most recently, we each started using Quest Diagnostics’ “Blueprint for Athletes” (BFA), a blood-based biomarker panel, to augment our testing and monitoring protocols.

The BFA allows the athletic performance staffs at Virginia Tech and Rutgers to take a more comprehensive approach to biological assessment. Using this blood testing panel, we both hope to accomplish two primary outcomes: educate student-athletes about their health behaviors and investigate methods for optimizing performance while decreasing injury risk and avoiding overtraining.

ABOUT BFA

The sports teams at Virginia Tech and Rutgers are not the first to use the BFA. It started as a collaboration between Quest Diagnostics and the New York Giants. The Giants wanted to use laboratory diagnostic information to maximize athlete performance, and from that wish, the BFA was born.

In its current iteration, the BFA starts with blood being drawn from athletes. About 50 to 70 milliliters is collected at a time, and the samples are then evaluated at the Quest Diagnostics lab. Results are typically available in a matter of days to weeks, depending on which biomarkers are being assessed.

From the blood tests, a BFA panel is compiled. A full panel can include readings for 40 or more biomarkers related to health, bioenergetics, endurance, muscle breakdown, recovery status, stress, inflammation, macronutrients, micronutrients, hydration, and allergies. The panel can also be catered to fit the needs of a specific team or athlete. For instance, at Virginia Tech and Rutgers, we rely on biomarkers related to:

• Cortisol

• Creatine kinase

• Iron

• Vitamin D

• Thyroid hormones

• Growth hormone

• Estrogen

• Testosterone

• Interleukin 6

• Omega 3

• Immunoglobulin E (IgE)

Simply testing for these biomarkers does no good without then applying the results to help athletes both on and off the field. Fortunately, the BFA provides actionable insight that can be utilized in training, sports medicine, and nutrition. Rather than just being numbers in a report, the results can be interpreted using proprietary methods to make concrete changes that will improve performance and reduce injury risk. That being said, the BFA findings must be interpreted by professionals in concert with other testing so that appropriate modifications can be implemented.

VIRGINIA TECH EXPERIENCE

Due to its ability to produce actionable results, Virginia Tech made the decision in 2015 to add the BFA to our screening processes for a select group of athletes. We chose to begin the program with football and women’s soccer in order to involve both a men’s and women’s sport. A total of 13 athletes participated.

The student-athletes and medical staffs for each squad were excited to take part in the BFA and obtain more information on ways they could improve. We convinced the sports coaches to partake through group discussions with their medical staffs, in which we explained the BFA, the kind of information we would learn from it, and the limited time required to complete the testing.

Once we had the coaches’ support, the inaugural testing began in the spring of 2016 and lasted through the completion of the following fall season. After the initial blood draw in the spring, further draws were completed at four time points: the start of preseason, the beginning of the competitive season, the mid-point of the competitive season, and the end of the season. This testing schedule helped us understand how the measured biomarkers changed throughout the season. Plus, it gave the athletes an opportunity to participate in the BFA without disrupting their training by testing too often.

The Virginia Tech research team received useful biomarker results from the BFA. Once all of the information from the panel was synthesized, we reviewed the athletes’ results and developed individualized programs for each of them. These varied based on the athlete’s fitness levels, nutritional deficiencies, or indicators of elevated systemic stress. The programs allowed the performance team-which was made up of the research, sports medicine, strength and conditioning, and sports nutrition staffs-to fine-tune nutrition and training regimens for each athlete to promote optimal performance and health based on the way their bodies acted at a cellular level.

For example, one aspect of the BFA testing we found useful was the allergy panel. This was based on IgE antibody serum results that were part of the initial blood draw. Some of the student-athletes had positive tests for previously unknown food allergies.

Armed with this information, the nutrition staff adjusted the athletes’ preparticipation fueling, recovery fueling, and general nutritional restrictions to avoid food sources that could lead to an allergic reaction. These results also enabled the medical and nutrition staffs to meet one of our broader goals by educating student-athletes about proper diet and explaining the importance of avoiding certain foods that could impact performance or hinder lifelong wellness.

Another helpful piece of data gathered from the BFA was each athlete’s different amino acid levels. With this information, we could determine how specific levels of amino acids impacted recovery and protein synthesis and use those findings to make our athletes feel better, avoid injury, and perform at an optimal level.

The BFA panel has been a great tool for Virginia Tech. However, one challenge we faced in implementing it was the time-sensitive nature of some of the information provided. The time and frequency of testing determines how actionable and useful the results are when trying to make changes to training and recovery. For instance, certain biomarkers, especially those pertaining to stress, are short-lived in the blood. They need to be reviewed quickly so they can be acted on quickly. If you are not testing often enough or at the right times, you could miss these biomarkers that could be useful in making changes to programming.

We experienced this firsthand. The gaps between our tests at Virginia Tech were not optimal for discerning some of the detailed biomarker information that is required to alter training programs as often as needed to improve performance during the fast pace of an athletic season. We believe minor modifications in testing time lines and turnaround times in receiving test results could help improve this in the future.

RUTGERS EXPERIENCE

At Rutgers, our use of the BFA differed from Virginia Tech’s in a number of ways. First, we started in the fall of 2015 with women’s soccer and field hockey and added men’s soccer the following fall. In total, we had 55 athletes participating in year one and 75 to 80 in year two.

We employed the BFA system because, unlike at Virginia Tech, the Rutgers field hockey and soccer teams had already been participating in extensive performance testing throughout the year, as well as on-field tracking using heart rate monitors and GPS devices. The BFA panel was considered the “next step” in athlete assessment. Our sport scientists and coaches realized that blood-based biomarkers had the potential to account for physiological factors beyond those provided by on-field monitoring and fitness testing. This was particularly true as it related to muscle breakdown, recovery, stress, inflammation, and nutritional markers.

Another important difference between Virginia Tech’s protocol and ours was the frequency of assessment. Rutgers’ players were tested every four weeks during the season and always within 18 to 36 hours after a game to determine changes in recovery patterns. We also tested every six to seven weeks in the offseason during year one.

This schedule was chosen so we could achieve a number of goals. First, from a research standpoint, it accounted for the menstrual cycles in the female athletes and allowed for consistency of timing in relation to intense activity, specifically games. Second, this testing interval was frequent enough to enable meaningful intervention during the season without being overly invasive for the athletes. Finally, this approach prevented our sport science staff from making spurious changes that could have come with more frequent testing.

When it came to interpreting and disseminating our BFA results, the sport science research staff took the lead, while the teams’ sports medicine staffs were involved when the panel raised any potential medical flags. These could include indicators of anemia, irregular or inappropriate hormonal responses, out-of-range immune system markers, and so on. The strength coaches and sport coaches were apprised of any notable findings and implemented the suggested changes to training. They were also fundamentally important in providing context to the BFA results because they saw the players every day and knew what was unique or different about individual practices.

With the findings from the BFA, we were able to identify players who were not adequately recovering, had developed nutritional deficiencies, or, in two cases, had previously undetected medical issues. The BFA biomarkers that allowed us to recognize these issues were signs of insufficient recovery (continually elevated breakdown, stress, and inflammatory markers; declines in iron or hemoglobin; and changes in growth hormone), along with training load indicators from GPS and heart rate monitoring.

Having this information enabled us to make rapid and effective intervention, which included educating athletes, giving extra rest during training, changing personnel rotation during games, providing nutritional support or adjusting supplements, or medical follow-up. While the GPS devices and heart rate monitors provided the primary foundation for quantifying training impact, we discovered the biomarkers were an important additional piece to the puzzle.

Using the BFA in conjunction with our other assessment tools, we’ve had no season-ending injuries with women’s soccer over the past two seasons. The team has seen the results on the field as well, advancing to the Final Four of the NCAA Division I Tournament in 2015 and making the second round in 2016. In the future, we may include more teams in the BFA or incorporate younger athletes. We may also look further into the impact of nutritional interventions.

There are some challenges to using biomarker testing appropriately-from determining the optimal testing times to deciding which biomarkers are actionable. However, the information provided helps keep athletes healthy by offering researchers, exercise physiologists, sports medicine personnel, strength and conditioning coaches, and nutritionists insights into the body’s recovery following strenuous physical activity. In addition, the assessment of blood-based biomarkers at the correct intervals could allow sports medicine and sports performance teams to identify athletes who are overtraining or undertraining and modify training programs accordingly. The integration of the BFA is a partnership that can benefit athletes long-term if they embrace the process and learn how to eat, train, and recover properly.

Sidebar:

COMPREHENSIVE SCREENING

The “Blueprint for Athletes” (BFA) program from Quest Diagnostics is just one of the ways Virginia Tech aims to maximize athlete performance and minimize injury. In fact, Virginia Tech has had a detailed preseason medical screening program in place since 2001 with the very same goals.

These assessments have allowed the sports medicine staff to identify at-risk athletes and initiate treatment before they begin training. In addition, the screens engage student-athletes in their personal health by integrating them into our system early on and introducing them to team physicians, sports nutrition, strength and conditioning, and athletic training staffs. Here’s a look at how we test for sickle cell trait (SCT), iron deficiencies, and cardiac issues:

Sickle cell trait: We test for SCT in a lab screening. All athletes who test positive are required to meet with our team physicians to discuss the results and become educated on the potential risks of playing sports with SCT. Further, we require these athletes to complete online training on SCT through the NCAA’s Sport Science Institute. They are then closely monitored and acclimatized during their training, both in and out of season.

Iron screening: The purpose of screening for iron deficiency is to identify clinically relevant, preexisting hematological abnormalities. Our goal as a medical staff is to ensure adequate hematologic testing for all “high risk sport” student-athletes. These individuals are identified by their team’s athletic trainer or a physician during a physical.

Between 2010 and 2012, we screened 149 student-athletes for iron deficiency, and 88 (59 percent) of them met the criteria with a ferritin level of less than 40. Any student-athlete who is found to have low ferritin levels receives dietary recommendations from one of our sports nutritionists, along with counseling from a team physician. They are also instructed to begin taking ferrous sulfate 325 milligrams (mg) (65 mg of elemental iron) two to three times daily on an empty stomach, with 500 mg of vitamin C to increase absorption.

Cardiovascular screening: Our cardiovascular screen provides student-athletes with a determination of medical eligibility for competitive sports by identifying (or raising suspicion of) clinically relevant, preexisting abnormalities. Any athlete identified as “high risk” based on their medical history and physician’s exam is given an electrocardiogram (ECG). Once the physician has reviewed the ECG, it is sent to the team cardiologist for analysis.

From 2008 to 2013, we studied cardiac screenings for athletes from 14 different sports. A total of 388 student-athletes (11 percent) tested positive for potential cardiac issues and received a subsequent ECG. There were 13 different categories of findings from these ECGs, and the most common (28 percent) was that of “normal” or no pathological finding or abnormality.

— Keith Doolan and Frederick Purnell


Robin Queen, PhD, FACSM, is the Director of the Kevin Granata Biomechanics Lab at Virginia Tech and an Associate Professor of Biomedical Engineering and Mechanics at the school. She is also an Associate Professor of Orthopaedic Surgery at the Virginia Tech Carilion School of Medicine. Dr. Queen can be reached at: [email protected]. Keith Doolan, MSEd, ATC, is the Senior Director of Sports Medicine for Virginia Tech athletics. He can be reached at: [email protected]. Frederick Purnell, MSEd, ATC, is a Director of Sports Medicine for Virginia Tech athletics. He can be reached at: [email protected]. Shawn Arent, PhD, CSCS*D, FISSN, FACSM, is Director of the Institute for Food, Nutrition, and Health's Center for Health and Human Performance at Rutgers University and an Associate Professor in the school's Department of Kinesiology and Health. Dr. Arent can be reached at: [email protected].
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