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

2. Individualized Treatment Via Applied Kinesiology
100% Holistic Approach:
Assessment, Treatment, and Lifestyle Changes
Rehabilitation
Prevention
Enhancement
Copyright Stephen Gangemi DC, DIBAK & SockDoc

3. 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?

4. Assess –> Treat –> Challenge –> Treat
Repeat as necessary
Advise and Educate

5. Why Do Athletes Get Injured?
Diet
Training
Lifestyle
Gear
Trauma

6. 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?

7. Training: The Exercise Part
Aerobic Conditioning
Anaerobic Conditioning
Strength
Economy/Form
Flexibility
But it’s so much more than working out.

8. Training = Working Out + Daily Stress Rest & Recovery Gangemi/SockDoc
Training Formula
Training = Working Out + Daily Stress Rest & Recovery
Gangemi/SockDoc

9. Copyright Stephen Gangemi DC, DIBAK & SockDoc
Gear (Footwear)
Sport Dependent
Footwear
Barefoot?
Minimalist?
Orthotics?
Copyright Stephen Gangemi DC, DIBAK & SockDoc

10. Copyright Stephen Gangemi DC, DIBAK & SockDoc
Acute Injuries
Inflammation – Control and Embrace It
Pain
Swelling
Loss of Function
Heat & Redness
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11. Copyright Stephen Gangemi DC, DIBAK & SockDoc
Acute Injuries
RICE:
Rest
Ice
Compress
Elevate
Copyright Stephen Gangemi DC, DIBAK & SockDoc

12. 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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13. Copyright Stephen Gangemi DC, 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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

14. Copyright Stephen Gangemi DC, 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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

15. Copyright Stephen Gangemi DC, 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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

16. Copyright Stephen Gangemi DC, DIBAK & SockDoc
Myofascial Release
Sarcomere contraction affecting blood flow
Powerful and immediate (hide a fx)
Overlooked and underestimated
Copyright Stephen Gangemi DC, DIBAK & SockDoc

17. Copyright Stephen Gangemi DC, DIBAK & SockDoc
INJURY FIRST AID
Reconsider Ice
Compress and treat
Natural anti-inflammatories (diet, herbs)
Prevention with AA, not NSAIDs
Copyright Stephen Gangemi DC, DIBAK & SockDoc

18. 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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

19. An Athlete’s Best Friend
ARACHIDONIC ACID
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20. Copyright Stephen Gangemi DC, 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)
Copyright Stephen Gangemi DC, DIBAK & SockDoc

21. Some Athletes Will Never Listen
They suffer from this complicated injury:
Copyright Stephen Gangemi DC, DIBAK & SockDoc

22. 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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

23. Copyright Stephen Gangemi DC, 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?
Copyright Stephen Gangemi DC, DIBAK & SockDoc

24. Copyright Stephen Gangemi DC, 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.
Copyright Stephen Gangemi DC, DIBAK & SockDoc

25. 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)
Copyright Stephen Gangemi DC, DIBAK & SockDoc

26. 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 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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27. Copyright Stephen Gangemi DC, DIBAK & SockDoc
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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

28. 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.
Copyright Stephen Gangemi DC, DIBAK & SockDoc

29. Copyright Stephen Gangemi DC, DIBAK & SockDoc
Train Smart
This is not aerobic conditioning:
This should not be your only “cardio”:
Copyright Stephen Gangemi DC, DIBAK & SockDoc

30. 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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31. Copyright Stephen Gangemi DC, DIBAK & SockDoc
Should You Stretch?
Copyright Stephen Gangemi DC, DIBAK & SockDoc

32. 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

33. Copyright Stephen Gangemi DC, 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.
Copyright Stephen Gangemi DC, DIBAK & SockDoc

34. 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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

35. 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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

36. 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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

37. MOVE Well and Often For Natural Flexibility
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38. Copyright Stephen Gangemi DC, DIBAK & SockDoc
Full Squat
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39. Improve Your Health Barefoot
Proprioception (sense of position)
Kinesthetic sense (the feedback your nervous system receives from your feet)
Copyright Stephen Gangemi DC, DIBAK & SockDoc

40. 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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

41. 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

42. 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 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 Saxena et al, 2003
Copyright Stephen Gangemi DC, DIBAK & SockDoc

43. How Long Do You Want to Support Your Patient?
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44. Copyright Stephen Gangemi DC, DIBAK & SockDoc
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

45. 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

46. Copyright Stephen Gangemi DC, DIBAK & SockDoc
Paradigm Shift
Don’t “stretch”  Move 
Don’t ice  Move, compress, treat
Aerobic conditioning before HIIT
Move minimalistically & barefoot
Eat more better
butter
Copyright Stephen Gangemi DC, DIBAK & SockDoc

47. Copyright 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
Copyright Stephen Gangemi DC, DIBAK & SockDoc

48. Copyright Stephen Gangemi DC, DIBAK & SockDoc
Natural Injury Treatment & Prevention for the Athlete Within
Copyright Stephen Gangemi DC, DIBAK & SockDoc