A Holistic Approach to Injury Treatment, Rehabilitation, and Prevention in Athletes Stephen Gangemi, DC, DIBAK ICAK ANNUAL MEETING - JUNE 2013.

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,

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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

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Gear (Footwear)

• Sport Dependent• Footwear

– Barefoot?– Minimalist?– Orthotics?


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Acute Injuries

• Inflammation – Control and Embrace It– Pain– Swelling– Loss of Function– Heat & Redness


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Acute Injuries

• RICE: – Rest– Ice – Compress – Elevate


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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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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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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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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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Myofascial Release

• Sarcomere contraction affecting blood flow• Powerful and immediate (hide a fx)• Overlooked and underestimated


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INJURY FIRST AID

• Reconsider Ice• Compress and treat• Natural anti-inflammatories (diet, herbs)

– Prevention with AA, not NSAIDs


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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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An Athlete’s Best FriendARACHIDONIC ACID


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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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Some Athletes Will Never ListenThey suffer from this complicated injury:


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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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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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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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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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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

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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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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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Train Smart

• This is not aerobic conditioning:

• This should not be your only “cardio”:


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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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Should You Stretch?


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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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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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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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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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MOVE Well and Often For Natural Flexibility


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Full Squat


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Improve Your Health BarefootProprioception (sense of position) Kinesthetic sense (the feedback your nervous system receives from your feet)


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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


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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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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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How Long Do You Want to Support Your Patient?


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Gait & Movement• The nervous system thrives from movement and sensory input• Improve stability with instability


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• Expanded Gait Assessment - updated at drgangemi.com under “Research”

http://www.drgangemi.com/wp-content/uploads/2011/01/GANGEMI-GAIT.pdf

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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Paradigm Shift

• Don’t “stretch” Move • Don’t ice Move, compress, treat• Aerobic conditioning before HIIT• Move minimalistically & barefoot• Eat more better


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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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Natural Injury Treatment & Prevention for the Athlete Within

http://sock-doc.com


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A Holistic Approach to Injury Treatment, Rehabilitation, and Prevention in Athletes Stephen Gangemi, DC, DIBAK ICAK ANNUAL MEETING - JUNE 2013.

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