A Holistic Approach to Injury Treatment

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A Holistic Approach to Injury Treatment,
Rehabilitation, and Prevention in Athletes
Stephen Gangemi, DC, DIBAK
ICAK ANNUAL MEETING - JUNE 2013
Individualized Treatment Via Applied Kinesiology
• 100% Holistic Approach:
• Assessment, Treatment, and Lifestyle Changes
• Rehabilitation
• Prevention
• Enhancement
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
2
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 –> Treat
Repeat as necessary
Advise 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?
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
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Acute Injuries
• Inflammation – Control and Embrace It
– Pain
– Swelling
– Loss of Function
– Heat & Redness
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DIBAK & SockDoc
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Acute Injuries
• RICE:
– Rest
– Ice
– Compress
– Elevate
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DIBAK & SockDoc
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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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DIBAK & SockDoc
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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
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
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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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DIBAK & SockDoc
18
An Athlete’s Best Friend
ARACHIDONIC ACID
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DIBAK & SockDoc
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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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DIBAK & SockDoc
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Some Athletes Will Never Listen
They 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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DIBAK & SockDoc
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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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DIBAK & SockDoc
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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 timeefficient 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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DIBAK & SockDoc
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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)
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
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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.
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
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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.
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
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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 Barefoot
Proprioception (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)
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
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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
• Expanded Gait Assessment
- updated at drgangemi.com under “Research”
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
44
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
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
45
Paradigm Shift
•
•
•
•
•
Don’t “stretch”  Move

Don’t ice  Move, compress, treat
Aerobic conditioning before HIIT
Move minimalistically & barefoot
Eat more better
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
46
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
Copyright Stephen Gangemi DC,
DIBAK & SockDoc
47
Natural Injury Treatment & Prevention for the Athlete Within
http://sock-doc.com
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DIBAK & SockDoc
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