Athletic Career Research Articles

Psychological and social factors associated with mental health of European dual career athletes: A systematic review.

Dual careers (DCs) are challenging trajectories followed by athletes willing to develop their academic/professional career with their athletic careers. These trajectories usually entail additional stressors, which can decrease athletes' mental health or even increase their risk of mental ill-health. While existing research has recognized the importance of psychological and social factors in both of these areas separately, we lack systematic knowledge on which factors are associated with European DC athlete mental health outcomes, making evidence-based practice more challenging. In this regard, to advance the European DC tradition and to provide a strong base for researchers and practitioners working within this field, this systematic review aims to appraise this evidence identifying and categorizing the psychological and social factors associated with the European DC athletes' mental health. We conducted this review according to Preferred Reporting for Systematic Reviews and Meta-Analysis guidelines and performed the systematic search in six databases, finding 56 eligible articles. Our analysis identified 35 different psychological and social factors, most showing significant associations with athletes' mental health. Notably, affect, stress, motivational climate, mindfulness, resilience, perfectionism, goal orientation, motivation, and basic psychological need satisfaction showed the strongest evidence associated with mental health. Overall, this review provides a comprehensive synthesis of psychological and social factors, advancing the holistic ecological approach in dual careers and athlete mental health. Yet, our results highlight the need to strengthen the evidence regarding these factors and provide specific research avenues, such as focus on DC-specific factors and consideration of DC athlete definition and career trajectories.

Impact of sports sponsorship on early career athlete performance: Czech case study

The purpose of this study is to investigate the correlation between sponsorship and the performance and development of early career athletes transitioning from junior level to professional sports, because this issue has not been fully explored in the Czech Republic. The reason is the almost absolute absence of financial or material support for such early-career athletes, when their transition from junior categories and the entire junior category is almost always exclusively financed and supported by their parents and families. We also emphasise the absolute absence of legislative provisions that would give supporters of such athletes at least a tax or other advantage. The research is based on research of Cardenas (2023), Hong and Fraser (2023) and Moolman and Shuttleworth (2023) and aims to assess how financial and material support provided by sponsors can enhance an athlete’s performance and long-term career trajectory. A mixed method approach was adopted, combining quantitative analysis through surveys and performance data with qualitative interviews. Data from 173 early career athletes from various disciplines were analysed using t-tests and ANOVA statistical methods to assess financial stability, access to better training, and community participation. Results indicate that sponsorship significantly contributes to better performance metrics, with sponsored athletes showing a 20% improvement in competition results compared to nonsponsored athletes. Furthermore, sponsorship financial support improved training opportunities and access to elite facilities, which was shown to increase athletes’ performance by 15%. However, some challenges related to sponsorship obligations, such as marketing commitments, were highlighted by athletes, underscoring the pressures that sponsorship can introduce. The implications of this study suggest that effective sponsorship strategies can play a vital role in an athlete’s career development, offering not only financial stability but also opportunities for personal branding and increased community engagement. Another implication is a possible consideration for legislators in the context of preparing a legislative framework enabling tax or other benefits for companies and organisations sponsoring or supporting these young athletes. More research is recommended to explore the long-term impact of sponsorship on athlete mental health and career sustainability, as well as the differences in sponsorship effects across various sports disciplines.

Long-term Prognosis of Patellar Tendinopathy (Jumper’s Knee) in Young, Elite Volleyball Players: Tendon Changes 11 Years After Baseline

Background: The long-term prognosis of jumper's knee and whether structural changes in the patellar tendon persist is unknown. Purpose: To investigate whether limitations in knee function and structural changes persisted beyond the athletic career of young elite volleyball players. Study Design: Cohort study; Level of evidence, 2. Methods: Volleyball players (mean ± SD age, 18 ± 0.8 years) enrolled in 2006-2011 in a prospective cohort study were invited in 2020-2022 to a follow-up study. Participants rated their knee function with the Victorian Institute of Sport Assessment–Patellar Tendon (VISA-P) score (baseline and follow-up) and the International Knee Documentation Committee (IKDC) score (follow-up) and reported if jumper's knee had influenced their decision to retire from sport. Tendon thickness and structural changes were assessed with ultrasound (baseline) and magnetic resonance imaging (MRI) (follow-up) of both patellar tendons. Results: We included 138 of 143 former athletes (97%) 11.4 ± 1.6 years after their baseline examination. At baseline, 37 persons (52 knees) had developed jumper's knee. At follow-up, participants reported lower knee function scores in knees diagnosed with jumper's knee at baseline than healthy knees (VISA-P scores: jumper's knee, 81 [95% CI, 70-92]; healthy, 90 [95% CI, 86-94]; P < .001; IKDC scores: jumper's knee, 82 [95% CI, 75-89]; healthy, 92 [95% CI, 91-95]; P < .001). Jumper's knee problems directly caused 7 of the 37 athletes (19%) with jumper's knee at baseline to retire from competitive volleyball. Of the 138 players included, 97 (70%) completed a bilateral MRI examination (194 knees). At follow-up, 38 of the 54 abnormal tendons (70%) had no structural changes (P < .001 vs baseline) while 22 of the 140 normal tendons (16%) had developed structural changes. Clinical symptoms were not correlated with tendon structure at follow-up (VISA-P scores for normal tendons: 85 [95% CI, 73-87]; abnormal: 89 [95% CI, 85-92]; P = .48). Conclusion: Jumper’s knee is not a self-limiting condition; volleyball players who had developed jumper's knee during adolescence reported persistent reductions in knee function 11 years later, leading one-fifth to retire from competitive volleyball. Although approximately 70% of tendons with structural changes at baseline were normal at follow-up, there was no clear relationship between structure and function.

Triad of female athletes

The female sports triad is a spectrum of dysfunctions related to energy availability, menstrual function, and bone mineral density. Energy availability is considered the trigger for the triad. Scientists have proven that women who do sports consume approximately 30% less energy and carbohydrates in relation to their body weight. Sufficient energy availability ensures the presence of a menstrual cycle, directly affects the stimulation of the production of female sex hormones (estrogen in particular). Thus, it prevents resorption of bone tissue. When energy availability is too low, a physiological mechanism reduces the amount of energy used for cell maintenance, thermoregulation, growth, and reproductive function. This compensation tends to restore energy balance and promotes survival, but impairs health. Low body weight in women of reproductive age, particularly in adolescence and the first reproductive age, is a biological marker of somatic and reproductive dysfunction. Osteoporosis in young female athletes is manifested by fractures unusual for young women or by frequent and multiple bone fractures during an athletic career. In this review article, an analytical review of literary and informational sources regarding the history of research on the problem of the triad of female athletes is carried out. The specifics of the negative impact of the athlete triad on the female body, the components of the athlete triad (amenorrhea, eating disorders, and osteoporosis) are examined in detail. The article focuses on its main cause - energy imbalance. The impact of the triad of female athletes on the psyche and behavior is considered. The question of its consequences for health both in the short-term and in the long-term perspective is considered. The prevention of RED-S syndrome was also investigated. The purpose of the study: Systematization of current knowledge about the triad of female athletes (relative energy deficiency syndrome (RED-S)). Research methods. Theoretical analysis of literary sources, systematization, generalization of scientific-methodical and special literature.

Transferability of the competences acquired in the elite athlete career to the project manager role analysis

What personal competences of successful project managers are determined by their former career as an elite athlete? To answer the question, comprehensive research is carried out, implemented as part of the EEIG-EU/P-Kr/06.12/23 project. The primary aim is to establish conclusively which particular personality traits, identified and analysed using the Big Five Inventory-2 and supplemented by structured interviews, directly contribute to the success of former elite athletes transitioning into roles as effective project managers. We found that successful project managers who were also elite athletes possess personality traits that can be identified as positive determinants of success in either sport or professional careers. Among these personality traits, we can include a low level of neuroticism and a high level of conscientiousness, then extraversion and agreeableness. This paper contributes to a nuanced understanding of how the realms of sports and management intersect and overlap. The presented paper can serve as a basis for further research in the field of personality psychology and management studies.

Training Model for Extended Career Athletes: A Narrative Review.

Today's elite and professional sports tend to feature older, more seasoned athletes, who have longer sporting careers. As advancing age can potentially limit peak performance, balancing training load is necessary to maintain an optimal state of performance and extend their sports career. To describe an appropriate training model for extended career athletes. Medline (PubMed), SPORTDiscus, ScienceDirect, Web of Science, and Google Scholar. A search of the literature between January 1, 2015 and November 22, 2023 was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Narrative review. Level 4. Data were extracted from studies related to the management of training and performance of athletes with extended and long careers. A total of 21 articles related to extended careers were found. Key themes from these papers included: expertise, biological maturation, and specificity; epidemiology and health; athlete monitoring; strength training; load management and detraining; success management. A training model for extended career athletes should balance the deleterious effects of age with the athletes' knowledge of, and expertise within, the sport. Designing specific training that accommodates previous injuries, training load intolerances, and caters for quality of life after retirement should be key considerations. Load management strategies for athletes with extended careers should include strength training adaptations to minimize pain, load-response monitoring, a broad range of movement, recovery and intensity activities, and the avoidance of large training load peaks and periods of inactivity.

An examination of the relationship between burnout and grit in college athletes

Burnout symptoms are a detrimental concern many athletes have at some point throughout their athletic careers. In order to assist athletes with performing at their optimal level, there is a need to better understand the burnout phenomena and the ways it can interact with other performance variables, such as grit. Given that grit is a predictor of success in a variety of domains (e.g., Duckworth & Yeager, 2015; Eskreis-Winkler et al., 2014; Fernández-Martin et al., 2020), the purpose of the study was to examine the relationship between grit and burnout. It was hypothesized that there would be an inverse correlation between grit and burnout. Grit and burnout data was collected from Division I student-athletes (n = 241) towards the end of their competitive seasons. Further, the student-athletes year in college was considered as a potential moderator between grit and burnout. The results indicated that student-athletes who scored higher in grit, also scored higher in burnout, hence the hypothesis was not supported. Additionally, there was a stronger positive relationship between grit and burnout for first-year students and sophomores, when compared with juniors and seniors. It is plausible athletes who are grittier are more likely to persevere through stress and challenges, including burnout symptoms, especially during their first two years of college. Athletes higher in grit may also be investing more effort into their sport, which could be increasing symptoms of burnout, as well. The results of this study warrant further investigation to clarify the interaction between grit and athlete burnout.

Exploring pregnancy and postpartum experiences among geographically diverse elite athletes: A qualitative study

ObjectivesFemale athletes who experience childbirth during their athletic careers can expect to return to elite sports postpartum and perform at a comparable or improved level. However, mothering athletes often encounter significant barriers when re-entering elite sports. The aim of this study was to explore the experiences of a geographically diverse group of mothering athletes who returned to elite sports after childbirth. DesignQualitative phenomenological research design using semi-structured interviews. MethodsIn-depth one-on-one interviews were conducted with nineteen mothering elite running athletes hailing from fourteen different countries. Interviews were recorded, transcribed verbatim, and analyzed using thematic analysis. ResultsFindings were generated into five main themes: (1) Deciding to become a mother, (2) revealing pregnancy to stakeholders, (3) experience of pregnancy, (4) combining motherhood and elite running, and (5) improvement strategies to support athlete mothers. The findings revealed that participants experienced stress regarding their pregnancy announcements due to concerns about potential repercussions on their careers. These concerns included the impact on sponsorship deals, relationships with governing bodies, and interactions with their coaches. Participants felt their elite coaches and health practitioners had insufficient education to support them throughout their pregnancies and postpartum return to elite running. Finally, athletes express a sense of diminished pressure and increased motivation in races upon resuming their elite careers, attributing their improved athletic performance postpartum to their shift in focus from themselves to their child. ConclusionsThis study illuminates challenges and offers valuable insights to coaches, sponsors, health practitioners, exercise professionals, researchers, race organizers, and governing athletic bodies in better supporting mothering athletes.

Lifetime Concussion History, Sleep Quality, And Pain Interference Following A Collegiate Athlete Career

Lifetime Concussion History, Sleep Quality, And Pain Interference Following A Collegiate Athlete Career

Associations Between Head Trauma Exposures, Mental Health, And Cognitive Health Following A Collegiate Athletic Career

Associations Between Head Trauma Exposures, Mental Health, And Cognitive Health Following A Collegiate Athletic Career

Low back pain or injury before collegiate athletics, a potential risk factor for non-contact athletic injuries.

Majority of research surrounding the predictive value of clinical measurements and assessments for future athletic injury does not differentiate between contact and non-contact injuries. We assessed the association between clinical measures and questionnaire data collected prior to sport participation and the incidence of non-contact lower extremity (LE) injuries among Division III collegiate athletes. Prospective cohort study. University setting, NCAA Division III. 488 Division III freshmen athletes were recruited to participate in the study during their preseason physical examinations. 10,983 public schools. Prospective incidence of non-contact Lower extremity Injury. Athletes completed questionnaires to collect demographics and musculoskeletal pain history. Clinical tests, performed by trained examiners, included hip provocative tests, visual appraisal of a single leg squat to identify dynamic knee valgus, and hip range of motion (ROM). Injury surveillance for each athlete's collegiate career was performed. The athletic training department documented each athlete-reported, new onset injury and documented the injury location, type, and outcome (days lost, surgery performed). Univariable Generalized Estimating Equations (GEE) models were used to analyze the relationship between each clinical measure and the first occurrence of non-contact LE injury. An exchangeable correlation structure was used to account for repeated measurements within athletes (right and left limbs). Of the 488 athletes, 369 athletes (75%) were included in the final analysis. 69 non-contact LE injuries were reported. Responding "Yes" to "Have you ever had pain or an injury to your low back" was associated with an increased risk of non-contact LE, odds ratio = 1.59 (95%CI 1.03- 2.45, p=.04). No other clinical measures were associated with increased injury risk. A history of prior low back pain or injury was associated with an increased risk of sustaining a non-contact LE injury while participating in NCAA Division III athletics.

"Health is Just the Basic Requirement for Optimal Performance and Winning": Stakeholders' Perceptions on Testing and Training in Competitive Alpine Skiing, Snowboarding and Freestyle Skiing.

Competitive alpine skiing, snowboarding and freestyle skiing, all different in nature and risks, are known for their high injury and illness burden. Testing measures and training methods may be considered for athletes' preparation to support performance enhancement while safeguarding their health. We explored the perspectives and perceptions of competitive alpine skiing, snowboarding and freestyle skiing stakeholders regarding testing and training practices in their competitive snow sports. We conducted an exploratory qualitative study based on grounded theory principles through 13 semi-structured interviews about testing and training practices with athletes, on-snow and off-snow coaches, managers and healthcare providers from different national teams. The interviews were inductively analysed through a constant comparative data analysis. Participants described winning as the end goal of testing and training practices, which requires athletes to perform in their best condition. To do so, they mentioned two main targets: performance enhancement and health protection. Participants acknowledged health as a premise to perform optimally, considering testing and monitoring approaches, goal setting, and training to support and protect athlete performance. This continuous cyclic process is driven by communication and shared decision making among all stakeholders, using testing and monitoring outputs to inform goal setting, training (e.g. on-snow and off-snow) and injury prevention. Such an approach helps athletes achieve their goal of winning while being fit and healthy throughout their short-term and long-term athletic career development. The ultimate goal of testing measures and training methods in such competitive snow sports is winning. Performance enhancement and health protection act as pillars in systematic, tailored and flexible processes to guarantee athletes' best preparation to perform. Moreover, athletes' assessments, goal setting, monitoring tools, open communication and shared decision making strongly guide this cyclic process.

Pulsed Electromagnetic Field (PEMF) stimulation as an adjunct to exercise: a brief review.

Pulsed Electromagnetic Field (PEMF) therapy is a non-invasive treatment that utilizes electromagnetic fields to stimulate and promote natural healing processes within the body. PEMF therapy works by emitting low-frequency electromagnetic pulses, which penetrate deep into tissues and cells, enhancing cellular function and health. PEMF applications are vast, ranging from enhancing recovery in athletes to supporting overall well-being in everyday individuals. PEMF therapy is increasingly recognized in the realm of sports and physical activity for its profound benefits in enhancing performance, accelerating recovery, and preventing injuries. By improving circulation, enhancing tissue oxygenation, and promoting the body's natural healing processes, PEMF therapy has become an invaluable tool in sports medicine, contributing to optimized physical health and prolonged athletic careers. In this review, we explore the effects of PEMF on exercise and the underlying physiological mechanisms.

Student athlete career management: A systematic review

The research aims to locate and examine articles discussing student-athlete career management worldwide, spanning from middle school to college. The targeted articles are those published from 2020 to 2024, in the form of English-language open-access research articles. The search involves the use of keywords such as “student-athlete, career, and management.” Data retrieval was conducted from two journal databases, namely ScienceDirect and Emerald, employing an article screening process guided by PRISMA guidelines. This process resulted in the identification of 5 relevant articles out of a total of 110. Screening was conducted systematically, encompassing the review of titles, abstracts, and full article contents to ensure comprehensive results. Mendeley software was utilized for article screening, and VOSviewer for data analysis. The findings indicate the necessity for future research to explore suitable support models for student-athletes, involving the engagement of government, schools/universities, and parents as mentors. This collaborative approach aims to establish a supportive environment for student-athletes, lessening the burden they face due to the demands of their dual careers.

An Athlete-Centered Career Assistance Intervention Program for the Chinese Sport System: Reflections Into Polyphonics

The aim through this manuscript is to share our career intervention situated in individual, group, and meta-reflective practice, to help elite athletes manage changes in their careers and support their autonomy and development within the Chinese Whole Nation System (CWNS). Translating findings from a science to practice project, we provide an athlete-centered reflective intervention integrating the perspectives of sport psychology practitioners (SPPs), coaches, athletes, and parents from a Chinese collective vantage. First, we introduce how athlete career transition scholarship and theoretical frameworks guided this intervention. Second, we explain how different levels of reflective practice can be used as a part of a career intervention. Third, we provide a brief summary of recent research project from which the intervention was derived, and fourth, we describe a six-step intervention to inform future implementations.

The Development and Validation of a Disordered Eating Screening Tool for Current and Former Athletes: The Athletic Disordered Eating (ADE) Screening Tool.

Current and former athletes are one of the most at-risk population groups for disordered eating (DE), impacting their dietary practices, body composition, performance and health during and following their athletic careers. Few comprehensive DE screening tools exist for this group. To help address this, the current study utilised a mixed-methods approach of Classic Test Theory (CTT) and Item Response Theory (IRT) to develop and validate a DE screening tool suitable for current and former athletes. Novel scale development methodologies were used to develop and assess the validity (content, face, cross-cultural, construct), test-retest reliability, internal consistency reliability, factor analysis and Rasch analysis of a new DE scale. A new validated Athletic Disordered Eating (ADE) screening tool was created, with 17 items and four subscales (food control, bingeing, body control, body discontent), with an internal consistency reliability of 0.91, excellent content and construct validity, an Intraclass Correlation Coefficient of 0.97 and excellent Rasch model fit. The ADE screening tool has been dually developed for research purposes and as a clinically applicable screening tool to detect DE in current and former athletes and is suitable for a global use across sporting categories, diverse genders and levels of competition.

Analysis of Severe Spinal Injuries in Korean Elite Female Wrestlers

Women’s wrestling is actively practiced in many countries. While severe spinal injuries pose a threat to an athlete’s career and health, research on severe spinal injuries in female wrestlers remains limited. The aim of this study was to investigate the characteristics of severe spinal injuries and post-injury management in Korean female wrestlers. We enrolled 54 female wrestlers participating in the national team selection competition. Interviews were conducted to examine the characteristics of spinal injuries that resulted in a time loss of more than three weeks from training throughout their athletic careers and their post-injury management practices. Approximately 46% of participants experienced severe spinal injuries, and 52% faced re-injuries during their wrestling careers. These injuries predominantly occurred during technical training due to overuse during tackling and standing attacks. The most frequent injuries were lumbosacral disc injuries (72%) and cervical disc injuries (20%), with 36% requiring surgery. Nearly half of the injured athletes received specialized rehabilitation, yet roughly 76% resumed training without medical clearance. Athletes injured during their student years were notably less likely to receive specialized rehabilitation compared with those injured during their professional careers (p = 0.011). On average, athletes returned to play within 2.7 to 3.0 months. Spinal injury characteristics and post-injury management were not significantly different between the light- and heavyweight classes. While Korean female wrestlers are at a high risk of experiencing severe spinal injuries and re-injuries during their careers, appropriate post-injury management is often lacking, highlighting the need for proactive intervention by healthcare professionals to prevent recurrent spinal injuries in female wrestlers and to ensure safe return to training.

Elite Athletes and Worker Status

Abstract Recent research regarding the working conditions of elite athletes in Olympic sports in the European Union, Norway and the UK shows that most athletes are not in an employment relationship with a sports stakeholder such as a National Olympic Committee, sports governing body or club because legislation at a national level or the terms of a contract preclude their status as employees or workers. Elite athletes who are excluded from employee or worker status do not have access to valuable social and employment benefits and protections, for example, a pension entitlement or maternity benefits. This article highlights the complex contractual situation of elite athletes who are integrated into a national elite sports programme and the regulatory and legal frameworks in which they provide services during an athletic career and posits that elite athletes are workers irrespective of an athlete’s legal status designated under national law or contract.

Examining the link between coach-athlete relationship and athlete burnout among college soccer players: the mediating role of training satisfaction.

Athlete burnout is an adverse factor that usually decreases athletes' sports performance and reduces their passion for athletic career development. The present study examined the association of coach-athlete relationship, training satisfaction, and athlete burnout, and then explored the training satisfaction as a mediating role of the effect of coach-athlete relationship on athlete burnout among college soccer players. Soccer players from seven Chinese higher education institutions were recruited for the study. The participants were selected using stratified random sampling and included 218 participants. The Coach-Athlete Relationship Scale, Training Satisfaction Scale, and Athlete Burnout Questionnaire were used to collect data from the participants. Pearson's product-moment correlation analysis, linear regression analysis, and bootstrap method were conducted to analyze the collected data set. The results showed that (1) there was a significant correlation between coach-athlete relationship, training satisfaction, and athlete burnout. (2) coach-athlete relationship and training satisfaction significantly negatively predicted athlete burnout (β = -0.39, p < 0.001; β = - 0.29, p < 0.001). (3) training satisfaction had a significantly mediating effect on the relationship between coach-athlete relationship and athlete burnout (β = -0.15, p < 0.001, ES = 0.28). Coach-athlete relationship can not only directly negative impact athlete burnout but can also negatively influence athlete burnout through the mediating effect of training satisfaction. Therefore, we suggest the following to alleviate athlete burnout: on one hand, coaches can provide more communication opportunities for athletes to improve the coach-athlete relationship. On the other hand, teams can enhance training satisfaction by building team culture.

Effectiveness of Injection Strategies on Patients With Patellar Tendonitis (Jumpers' Knee): A Network Meta-analysis of Randomized Controlled Trials.

Patellar tendonitis (PT) is a common degenerative disease of the patellar tendon that seriously affects the sports careers of elite athletes and activities of daily living of sports enthusiasts. Injection therapy is a prevalent invasive treatment for PT. This work comprehensively analyzes various injection treatments for PT that consider agent type and characteristics, frequency, and assessment timepoints by meta-analysis. PubMed, Embase, and the Cochrane Library were sources of data. Randomized controlled trials (RCTs) analyzing the effect of various injection strategies on the treatment of patients with PT were considered. Systematic review and meta-analysis. Level 2. First author, year of publication, research location, registration information, patient type, sample size, age, sex, intervention, control treatment, and follow-up period in each study were extracted. Nineteen RCTs were included in the analysis. In the network meta-analysis of Victorian Institute of Sports Assessment-Patellar (VISA-P) outcomes, polidocanol (standardized mean difference (SMD), 6.52; 95% CI 4.75, 8.30; P < 0.01), tenocyte-like cells (SMD, 4.08; 95% CI 2.92, 5.25; P < 0.01), and leukocyte-poor platelet-rich plasma (LP-PRP) plus high-volume image-guided injection (HVIGI) (SMD, 1.56; 95% CI 0.62, 2.50; P < 0.01) were significantly superior to noninjection conservative treatment, mainly at the 6-month follow-up timepoint. For visual analog scale results, multiple dry needling (DN) (SMD, -1.78; 95% CI -2.56, -1.00; P < 0.01), LP-PRP (SMD, -0.71; 95% CI -1.31, -0.12; P = 0.02), and LP-PRP plus HVIGI (SMD, -1.31; 95% CI -2.22, -0.39; P < 0.01) were significantly superior to blank, which was also mainly at the 6-month timepoint. Injection-related treatments: polidocanol, tenocyte-like cells, LP-PRP, and multiple DN showed potential short (1-3 months) or medium (6 months)-term treatment benefits. There is still no evidence for injection interventions with long-term therapeutic benefit.