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Transcript of A Holistic Approach to Injury Treatment, Rehabilitation, and Prevention in Athletes Stephen Gangemi,...
A Holistic Approach to Injury Treatment, Rehabilitation, and Prevention in Athletes
Stephen Gangemi, DC, DIBAKICAK ANNUAL MEETING - JUNE 2013
• 100% Holistic Approach: • Assessment, Treatment, and Lifestyle Changes• Rehabilitation• Prevention• Enhancement
Individualized Treatment Via Applied Kinesiology
2Copyright Stephen Gangemi DC,
DIBAK & SockDoc
Treat the Cause or Symptom?Athletes often present with a multitude of factors
Ex: Plantar Fasciitis
•Inhibited tibialis posterior?•Past injuries?•Adrenal stress?•Poor footwear?•Insufficient/Poor diet?•Excessive training – Inadequate rest?
N = 1
Assess –> Treat –> Challenge –> TreatRepeat as necessaryAdvise and Educate
Why Do Athletes Get Injured?
• Diet• Training• Lifestyle• Gear• Trauma
Diet• Often incompatible with
current training & recovery
•Protein Gangemi 2010 (ICAK Proceedings)
•Carbs – (Dysglycemia) Gangemi 2009 (ICAK Proceedings)
•Fats•Micronutrients•Drugs (caffeine, meds)
• Is the diet enhancing, supporting, or deterring?
Training: The Exercise Part
• Aerobic Conditioning• Anaerobic Conditioning• Strength• Economy/Form• Flexibility
But it’s so much more than working out.
Training Formula
Training = Working Out + Daily Stress Rest & Recovery
Gangemi/SockDoc
Gear (Footwear)
• Sport Dependent• Footwear
– Barefoot?– Minimalist?– Orthotics?
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DIBAK & SockDoc
Acute Injuries
• Inflammation – Control and Embrace It– Pain– Swelling– Loss of Function– Heat & Redness
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DIBAK & SockDoc
Acute Injuries
• RICE: – Rest– Ice – Compress – Elevate
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DIBAK & SockDoc
ICE?
• Short window of opportunity after the injury BEFORE edema sets in: 30 minutes
• Prevention of swelling, not removing• Prevention of secondary injury via hypoxia
– Aerobic Anaerobic (buys time) Merrick et al, 2010
Knight, K L. Cryotherapy in Sports Injury Management
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DIBAK & SockDoc
ICE? Think Twice• Detrimental effect on proprioception Ribeiro et al, 2013
• Negative effect on dynamic medial/lateral balance Douglas et al, 2013
• Insufficient evidence that cryotherapy improves clinical outcome of soft tissue injuries Collins, 2008
• Exercise with ice allows active motion leading to increased blood flow (cryokinetics) Knight & Londeree, 1980
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DIBAK & SockDoc
ICE? Think Twice• “Duplicitous roles of neutrophils” limit inflammation and stimulate healing
after acute soft tissue injury Butterfield et al, 2006
• Benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use Adie et al, 2012
• Analgesic • Tendency to impair blood and lymph flow• Delayed healing likely• Does it facilitate an inhibited muscle? – Clinical Application• Type (gel pack, cubes in H2O, frozen veges?) & duration
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DIBAK & SockDoc
R - I - C - E?
• Rest: Active or Passive?• Elevation• Compression
– Myofascial release– Origin-Insertion– Trigger Point Work– Actual Joint/Tissue Compression
– Location, duration, frequency
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DIBAK & SockDoc
Myofascial Release
• Sarcomere contraction affecting blood flow• Powerful and immediate (hide a fx)• Overlooked and underestimated
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DIBAK & SockDoc
INJURY FIRST AID
• Reconsider Ice• Compress and treat• Natural anti-inflammatories (diet, herbs)
– Prevention with AA, not NSAIDs
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DIBAK & SockDoc
NSAIDs for Inflammation?
• For the unhealthy with an eicosanoid imbalance• Worse inflammation if you’re healthy –> prostaglandin
inhibition• Gastrointestinal, cardiovascular conditions, musculoskeletal,
and renal side effects Warden, 2010
• Poor adaptation to exercise• Poor hormone detoxification
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DIBAK & SockDoc
An Athlete’s Best FriendARACHIDONIC ACID
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DIBAK & SockDoc
ARACHIDONIC ACID
• Essential inflammation to repair and rebuild• Most abundant fat in the brain (with DHA)• Protects against tissue oxidation (major issue
with injury & inflammation)• Repair and growth of skeletal tissue• Immunological properties• NOT AA from vege oils + carbohydrates (D-5-D)
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DIBAK & SockDoc
Some Athletes Will Never ListenThey suffer from this complicated injury:
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DIBAK & SockDoc
HIIT: All the Kids Are Doing It!
• Interval training, currently touted as the best and most effective way to exercise
• High compliance rates (biggest bang for your buck)
• Raises growth hormone• Improves insulin sensitivity (affecting
metabolic syndrome)• Isn’t the “chronic cardio” that many
proponents say will only hinder health
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DIBAK & SockDoc
HIIT: All The Hype
• No set standards or agreement regarding – Frequency– Duration– Intensity
• How does it affect health?• What are the long term fitness consequences?• What is being measured?
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DIBAK & SockDoc
HIIT
“Repeated bouts near or above an athlete’s ventilatory/lactic threshold or work tolerance, performed with the intent to do more total work at higher intensities than would otherwise be possible at steady state.” – Brian Tabor, M.S. Ex. Phys
Many HIIT studies are not at high intensity or true interval training.
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DIBAK & SockDoc
What Does the Research Say About HIIT?
• Low volume HIIT increases skeletal muscle mitochondrial capacity and improves exercise performance Little et al, 2010
• *2 weeks, 8-12 x 60 s intervals 100% of peak power
• Insulin sensitivity improved 23% Babraj et al, 2009
• *2 weeks, 6 sessions; 4–6 × 30-s cycle sprints per session
• Exercise intensity related to improvements in insulin sensitivity; frequency was not Dubé 2012
• *16 weeks, 75% of peak HR for 45 min per session; 3-5X per week • (This is more aerobic training, not HIIT)
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DIBAK & SockDoc
What Does the Research Say About HIIT?
• Higher cortisol, lower free T3, lower free testosterone in interval group but not the steady state group Hackney et al, 2012
• *Interval session was 90 sec bursts - 90 sec recovery for 42-47 minutes. The steady state was 45 mins at 60-65% VO(2max).
• This is hard-core training, not HIIT
• Low volume sprint comparable to high volume endurance is a time-efficient strategy to elicit improvements in peripheral vascular structure and function Rakobowchuk, 2008
• Typically those short on time are already highly stressed
Copyright Stephen Gangemi DC, DIBAK & SockDoc
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HIIT vs. “Aerobic”• Intense endurance exercise causes acute dysfunction of the RV La Gerche et al,
2012 *Intense
• Long-term excessive sustained exercise may be associated with coronary artery calcification, diastolic dysfunction, and large-artery wall stiffening O'Keefe, 2012 *Excessive
• Cardiac fibrosis after long-term intensive exercise training Benito et al, 2011
*Male Wistar rats conditioned to run vigorously, 1 hr per day, 16 weeks, and often shocked electrically to do so
This is not true aerobic. It is hard cardio, primarily taxing anaerobic metabolism
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DIBAK & SockDoc
Aerobic & Anaerobic Guidelines
• Build a true aerobic base before you embark into HIIT training
• HIIT should be performed 2-4 times a week for 2-6 weeks, depending on each individual’s health, fitness, and goal (sport/level of competition)
• Interval intensity is dependent upon sport• Health first. Fitness second.
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DIBAK & SockDoc
Train Smart
• This is not aerobic conditioning:
• This should not be your only “cardio”:
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DIBAK & SockDoc
Aerobic & Anaerobic Challenge• AEROBIC CHALLENGE: Patient raises and lower
the legs alternately for 8-10 repetitions• ANAEROBIC CHALLENGE: Patient alternately
flexes and extends the forearms as rapidly as possible for at least 12 seconds
• CREATINE PHOSPHATE CHALLENGE: Patient alternately flexes and extends the forearms as rapidly as possible for 3 seconds
Gangemi 2009 (ICAK Proceedings)
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DIBAK & SockDoc
Should You Stretch?
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DIBAK & SockDoc
Stretching Flexibility
• Flexibility is primarily a reflection of the nervous system via the musculoskeletal system.
• Why do you need to stretch? Is longer better?• You cannot stretch yourself to health.• Stretching doesn't lengthen a shortened muscle
much unless it is performed often; strength and stability are often lost.
• Muscles are often tight due to poor mechanics, poor health, and the body trying to protect itself.
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DIBAK & SockDoc
Types of Stretching• Static stretch: Hold and stretch – seconds to minutes. (sitting toe touch)• Dynamic stretch: AKA dynamic warm-up, mobility drills, “moving naturally”; strength,
flexibility, balance, coordination enhancement (walking lunge, knee lifts). Move a joint through ROM which will give functional results for your sport.
• Active stretching: Own muscles without any aid • Passive stretch: Motion obtained from outside source – partner, rope, other devices• Active isolated stretch: contract the opposite/antagonist muscle; hold for <2 seconds, repeat
8-10 times, more ROM each time (lymph drainage and more O2 and blood flow)• PNF (proprioceptive neuromuscular facilitation): Motion combinations with resistance
(isometric and concentric) through full ROM via passive stretch• Plyometrics: Fred Wilt, former US long-distance runner coined after watching Russians jump
while Americans did ss,(ex: depth jumps). Eccentric-isometric-concentric in a very short time. Lengthened in eccentric. Often combined with dynamic stretches.
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DIBAK & SockDoc
The Research on Stretching• Static stretching as the sole activity during warm-up routine should generally be
avoided Simic et al, 2013
• 8.36% less strength and 22.68% less stability with static stretching over active dynamic warm-up Gergley, 2013
• Pre-exercise, PNF decreases performance; post exercise, it increases athletic performance along with range of motion Hindle et al, 2012
• Dynamic warm-up produced longer-term sustained power, strength, muscular endurance, and anaerobic capacity Herman et al, 2008
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DIBAK & SockDoc
The Research on Stretching• Those who stretched vs. those who didn’t were stronger, more flexible, and had more
endurance Kokkonen et al, 2007
– *19 sedentary people are told to static stretch 40min a day, 3 days a week, for 10 weeks. In other words – get up and move for a total of 2 hours a week. (moving = improving)
• Incorporating lengthened state eccentric training may help reduce the rate of reinjury Schmitt et al, 2012
• Dynamic stretching does not affect running endurance performance in trained male runners Zourdos et al, 2012
• Increasing ROM beyond function through stretching is not beneficial and can actually cause injury and decrease performance Ingraham, 2003
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Reasons For Stretching• Injury Prevention? Dynamic movements and mobility can help prevent
injury; static stretching doesn’t equate with quality and stability.• Performance Enhancement? No – strength & control is often lost with
stretching alone; only performance enhancement with certain activities that may require excessive ROM (martial arts, gymnastics, ballet)
• Injury Treatment? Movement: mechanical stimulation leads to tissue adaptation (fiber alignment and tissue synthesis). There are better alternatives than stretching without stressing muscles and connective tissue that is trying to heal. *Myofascial release
– Don’t compartmentalize, humans move dynamically• Relaxation (deep breathing & yoga – not stretching)• Eccentric Loaded Stretching Strength, Stability, Flexibility• Functional: The result Not what you’re doing but what it produces
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DIBAK & SockDoc
MOVE Well and Often For Natural Flexibility
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DIBAK & SockDoc
Full Squat
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38
Improve Your Health BarefootProprioception (sense of position) Kinesthetic sense (the feedback your nervous system receives from your feet)
39Copyright Stephen Gangemi DC,
DIBAK & SockDoc
Barefoot and Minimalism
• Shock absorption: Foot strike Heel or forefoot• Solid support: Loading Rate Center of mass• Energy & Power: Elastic Recoil Natural Spring
• Footwear impairs foot position awareness which may contribute to the frequency of falls Robbins et al, 1995
• Forefoot and midfoot strike gaits may protect the feet and lower limbs from impact-related injuries Lieberman et al, 2010
• Flat, flexible footwear results in significant reductions in knee loading in subjects with OA Shakoor et al, 2013
40Copyright Stephen Gangemi DC,
DIBAK & SockDoc
Orthotics & Arch Supports• No true long term studies of their effectiveness or consequences • They support dysfunction rather than correct or rehabilitate• Arch supports push up on the arch to “support” rather than truly support and rehabilitate
the arch where it should be supported – at the beginning (heel) and end (forefoot)
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DIBAK & SockDoc
Orthotics & Arch Supports• Orthotics control pain by restricting motion and changing mechanoreceptors Guskiewicz 1996
• 75% reduction in disability rating and a 66% reduction in pain rating with foot orthoses Gross et al, 2002
– *Plantar Fasciitis, orthotics worn only 12-17 days
• Orthotic use most influencing factors in medial tibial stress syndrome Hubbard et al, 2009
• Flexible arch support promotes a medial force bias during walking and running, significantly increasing knee varus torque Franz et al, 2008
• Orthotics related to a higher rate of knee and ankle pain Change et al, 2012
• Patellofemoral pain syndrome: Multiple treatment modalities in addition to orthotics. 76.5% improved; only 2% pain free. Ages 12-87. Saxena et al, 2003
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42
How Long Do You Want to Support Your Patient?
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DIBAK & SockDoc
Gait & Movement• The nervous system thrives from movement and sensory input• Improve stability with instability
44Copyright Stephen Gangemi DC,
DIBAK & SockDoc
• Expanded Gait Assessment - updated at drgangemi.com under “Research”
Oral Taste Receptors & The Brain
Oral Nutrient Testing
• Carbohydrate mouth rinsing improves endurance capacity in both fed and fasted states Fares & Kayser, 2011
• Improvement in high-intensity exercise performance with exogenous carbohydrate appears to involve an increase in central drive or motivation rather than having any metabolic cause Carter, 2004
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DIBAK & SockDoc
Paradigm Shift
• Don’t “stretch” Move • Don’t ice Move, compress, treat• Aerobic conditioning before HIIT• Move minimalistically & barefoot• Eat more better
46Copyright Stephen Gangemi DC,
DIBAK & SockDoc
Final Message
• Treat your patient athlete as the individual he/she is
• Don’t fall into the “latest and greatest” research trap
• Pain removal first and then focus on helping develop a faster, stronger, healthier, and more efficient athlete
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DIBAK & SockDoc
Natural Injury Treatment & Prevention for the Athlete Within
http://sock-doc.com
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DIBAK & SockDoc