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

Individualized Treatment Via Applied Kinesiology 100% Holistic Approach: Assessment, Treatment, and Lifestyle Changes Rehabilitation Prevention Enhancement Copyright 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?

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

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

Copyright Stephen Gangemi DC, DIBAK & SockDoc Acute Injuries Inflammation – Control and Embrace It Pain Swelling Loss of Function Heat & Redness Copyright Stephen Gangemi DC, DIBAK & SockDoc

Copyright Stephen Gangemi DC, DIBAK & SockDoc Acute Injuries RICE: Rest Ice Compress Elevate Copyright Stephen Gangemi DC, 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 Copyright Stephen Gangemi DC, DIBAK & SockDoc

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MOVE Well and Often For Natural Flexibility Copyright Stephen Gangemi DC, DIBAK & SockDoc

Copyright Stephen Gangemi DC, DIBAK & SockDoc Full Squat Copyright Stephen Gangemi DC, DIBAK & SockDoc

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

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

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

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 Copyright Stephen Gangemi DC, DIBAK & SockDoc

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

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

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

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

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

Copyright Stephen Gangemi DC, DIBAK & SockDoc Natural Injury Treatment & Prevention for the Athlete Within http://sock-doc.com Copyright Stephen Gangemi DC, DIBAK & SockDoc