Thursday, May 30, 2013

It can't be done? REALLY? The evidence suggests otherwise......

Admittedly, I am not a professional writer or master of prose.  I am, however, a person that has invested a lifetime pursuing methods of helping injured athletes at all levels achieve their goals and return to optimal performance.  Over the past twenty years of working with athletes during adversity, here is what I have learned........we humans are more capable than we believe, we just need a little help to guide us.

The evidence is all around us; elite athletes coming back from life threatening injuries to fully compete again....80 year olds fininshing an Ironman.....amputees taking back control of their lives and returning to competitive sports, etc. etc. etc.  Nearly all things are possible, but there are two key ingredients to make the seemingly impossible possible.   (1) A complete commitment of the individual to overcome and succed and (2) access to accurate information and resources to allow success.

Commitment is an individual choice, and nothing is possible without total commitment.  Commitment is personal and essential.  A motivational video or someone selling a program for "guaranteed success" may motivate us to start to tackle a goal, but unless there is complete conviction, success will be short lived if it is even achieved.

Access to accurate information and resources is another matter.  The "misinformation" highway that the common recreational or age-group athlete looks to for resources on recovering from injury or improving performance can be a little misleading, many times asking for a blind investment from a company, product, or individual and trusting what they are being told or sold will work.  Can most people afford this?  I think not.  In my position, however, we are able to evaluate and try most avenues being developed to help people achieve their physical goals, particularly when injured. The purpose of this blog is to share information from research and personal experience and make the trip on the "misinformation highway" a very short trip. I hope it will help others dealing with injuries and setbacks guide themselves to achieveing their goals.

Monday, May 27, 2013

The Insanity of Chronic Sports Injuries Revisited

They say insanity is doing the same thing over and over and expecting a different result.  Simply resting an overuse/chronic injury until it feels better then returning to sport only to see the problem arise again is (by definition) unnecessarily insane.  Resting and resolving symptoms won't necessarily correct an injury brought on by mechanical overuse.  The repeating stresses that bring on overuse injuries in an athlete must change, or the same resulting repeating injury will occur; to think otherwise is plain crazy (pun intended).  When an injury occurs, most athletes are told to treat the area with some type of physical modality to reduce their symptoms (i.e. ice, ultrasound, electrical stimulation, etc.), rest, and return to activity when feeling better.  They treat the resulting symptoms instead of addressing the source of the problem, return to activity, and, at some point, incur the injury condition again.  This is the insanity of chronic injuries. If you are in this category, there steps to take to stop the madness........

As athletes at all levels are now training year-round at higher and higher levels to achieve better performance, there is an inevitable accompanying risk of injuries to soft tissues.  Muscles, ligaments, tendons, and bones subjected to stresses that exceed their capacities result in injuries.  Sometimes this is an acute strain, but more often than not, it is a gradual onset of pain that eventually disrupts workout patterns and routines if not handled correctly and/or rested.  Ultimately, overuse injuries are caused by mechanical inefficiencies and/or imbalances of the body.  We all have differing areas of mechanical inefficiencies and thus have varying areas of soft tissue overload. This is why two people performing exactly the same workouts might have two different areas of soreness or injury following a workout. It is also why treating or rehabilitating an injury with the same methods for two different people might not yield maximum recovery results for both athletes.  Injury treatment regiments and injury rehabilitation programs should be individually constructed for every person, addressing the source of their problem to help reduce their symptoms and developing a specific plan accordingly.

In any soft tissue/overuse type of injury, determining the mechanical causes and developing correction strategies is the biggest challenge for the sports medicine specialist. What causes IT Band Syndrome in one athlete might be different than the cause of the same condition in another.  The same holds true for patellar tendonitis, plantar fasciitis, metatarsal stress fractures, SI joint/back pain, etc.  Athletes should be leery of a particular technique, product, or method that claims to "cure all of problem X".  There is no shortage of products being advertised reporting to be the complete remedy for all sorts of sports related maladies.  Pick up any fitness related magazine, and you will find the supposed sure fire cure for whatever sports related injury you might have.  Sadly, there are no immediate shortcuts to solving a chronic injury problem.  Most of these products can assist in treating the symptoms of injury and get pain to subside in the short term, but long term, the problem will most likely return unless other changes are made.  Some products can help to correct the mechanical problems leading to injury, but must be used specific to the injury condition to be effective.  It all seems quite confusing and leaves many people with chronic injuries feeling hopelessly helpless.

If you suffer from repeated injuries in particular areas, there are five general rules to follow to guide you to a maximum recovery with smallest chance for repeated injury:

1. Identify a sports medicine professional qualified and experienced in diagnosing mechanical problems and muscular imbalances in athletes and who has a track record of correcting these problems.  To help you with this, look for a certified athletic trainer (ATC), sports physical therapist (PT) or physiotherapist with experience in these areas.  Ask around for recommendations from higher level athletes, professional sports teams, or major colleges, or seek out professionals who work with athletes at the highest level.  They will be most familiar with these correction strategies.

2. Develop an understanding of the injury and it's causes and work with the specialist to develop a plan which corrects the problem's source, not just treating the symptoms. This must include a corrective exercise plan to address the identified mechanical issues which are causing the problem.  (If the person you are working with can't do this, you picked the wrong person)

3. With your sports medicine professional, develop a comprehensive corrective exercise plan to address your mechanical inefficiencies and adhere to it religiously!  Good sports medicine professionals will help you do this while working around your planned workout schedule.  This may include the use of specific devices or therapeutic techniques to help address the underlying mechanical problems that have resulted in injury.

4. Every good corrective exercise program will involve development and coordination of the core muscles during this program.  Without a strong core for a solid foundation, other corrective exercises may not be effective in the end.  (More on this in an upcoming blog)

5. Be cognizant of your limitations while recovering from the injury, adjust your workouts accordingly until the problem is resolved, then develop a progressive return to specific activity plan taking advantage of your new mechanical corrections. (alternative methods to maintaining your conditioning while injured was the topic of two previous blog posts).

6. Don't be closed minded to the fact that some of your workout choices, athletic gear (shoes, bike, racquet, etc), and workout conditions may be contributing to your problem.  Be prepared to make changes in areas within your comfort zone.  Athletes who find the right sports medicine professional and trust and adhere to their recommendations typically respond the best.

As promised in the last blog, we will focus on providing information to help guide you through all of the misinformation.  The next five blogs will focus on information from the five tips above to arm you with information to win the overuse injury battle and avoid the chronic injury asylum.

Until then, train hard, train safe, and train smart!

Monday, April 29, 2013

"Squeezing" the Most Out of Your Recovery

Recovery from vigorous workout sessions has become an important aspect in achieving optimal performance.  Athletic performance hinges nearly as much on proper recovery as proper training methods.  Heavy training inevitably results in tissue damage, soft tissue inflammation, and waste byproducts (typically referred to as edema). For effective recovery, tissue inflammation and edema must be removed to allow tissues to rebuild.  While we are slowly accepting that more training may not be necessarily better, we are also learning with heavy training, there are methods and techniques available to help us maximize potential for recovery.  This is achieved through moving and minimizing inflammation making our trek toward personal athletic performance excellence easier.

Recently, compression technology has gained popularity as means of enhancing recovery. There are several methods of compression available to athletes and all work to assist the body in minimizing the effects of heavy training. Common methods available to athletes are compressive garments and mechanical compressive devices. Both have their benefits.  Picking the appropriate method hinges on many factors.

Compression Recovery Theories
The theory behind compression technology is often misunderstood.  Without being overly scientific, to be effective, compression must surround the body part at a high enough level to affect fluid movement between tissues and blood vessels, ultimately ending with fluids being moved through tissues and into the lymphatic system for removal. With most compression devices, compression is graded with the distal portion of the device (furthest away from the heart) applying more pressure than the proximal portion of the device (closest to the heart).  The lymph system runs in this same direction, and the graded pressure promotes movement of fluids in the appropriate direction. 

Clinically, the use of compressive devices has been associated with creating pressures correlated to diastolic blood pressure (approximately 80 mmHg in a normal person).  However, arterial capillary pressures are approximately 30mmHg, and any pressures that exceed this theoretically should promote fluid re-absorption and movement of the lymph.  Squeezing of the lymph channels and increasing the hydrostatic pressure of the tissues can be accomplished with as little as 40-50 mmHg and will force fluids and edema through blood vessels promoting removal as well.  The importance of active movement of the body part, muscular contractions, and elimination of the effects of gravity in conjunction with compression enhances the fluid removal effects even greater (and are explained in a previous blog).  Understanding these pressure numbers is important when choosing your method of compression.

Mechanical Compression Devices.
Normatec MVP Sequential Compression
Mechanical compression devices have been utilized by sports medicine experts in professional, collegiate, and elite athletics for many years.  Mechanical compression devices are typically filled with air, cold fluids, or gels. Device pressures can be adjusted according to the desired effects.  These devices come with appliances for application on the upper and lower extremity.  Some devices apply uniform compression throughout the device while others have separate chambers capable of filling with pressures of varying levels.  One of the most popular compression devices is the Normatec MVP Pro (shown here). This device is utilized by top-level athletes and sports medicine professionals due to it's unique ability to alter pressure changes throughout the device and to perform a sequential filling and emptying of different areas of the device creating a massaging effect from distal to proximal.  Combined with elevation and taking advantage of the great effect of gravity, this device has quickly become a modality of choice for top sports medicine professionals and endurance sports teams for recovery and edema removal.  NormaTec has recently introduced a more affordable unit called the MVP Pro which contains the protocols used for recovery and is more affordable.  In the coming year, this will be a product that many age-groupers purchase to help their efforts.  Other products are entering the market in a lower price range (BioCompression Systems, Jobst, and Recovery Pump), but the adjustability and capabilities of these products is unknown at the time of writing of this blog.  The negative aspect of these machines are the cost.  However, many sports medicine clinics and clubs are purchasing sequential compression units and are becoming more readily available to the everyday athlete. Empirical evidence on the effectiveness of these products is very high.

Compression Garments
Another popular trend has been the application of compression garments before, during, or after competition.  Research on the application of these devices is sparse.  Considering the pressure numbers needed to achieve the desired results, it is a "buyer beware" market.  Before purchasing compression garments, it is wise to find out the pressure numbers provided by the garment.  Reputable manufacturers will have these numbers available to the consumer. Make sure to purchase compression garments that will provide the minimum pressures needed to have a desired effect.

Don't Overlook the Obvious
Exercise and movement of body parts promotes fluid movement and exchange.  Though compression garments might not provide enough pressure to cause a fluid shift independently, use of compression garments in conjunction with light exercise during recovery may have a positive effect.  Certainly, the use of compression garments in conjunction with elevation will provide good results.  Elevating the limbs is the most overlooked, yet likely one of the most effective tools available in recovery.  So, after your next strenuous workout, don't be afraid to cool down, stretch, shower, and then spend some quality time relaxing and recovering with your feet elevated.  Adding one of the devices above will simply enhance what mother nature wants us to do to recover.

Future blogs will report on other methods used to improve chances of training healthy and enhancing recovery.

Until next time, train safe and train smart!

Friday, April 26, 2013

Don't Want to Lose Conditioning While You Heal Up? -- " Go Off the Deep End!"

The biggest fear most athletes face when they get injured is the loss of hard earned conditioning levels. The biggest reason that most "Type A" athletes don't appropriately recover from overuse injuries is inappropriate rest for recovery due to these overwhelming fears.  There are as many recommendations for conditioning while injured as there are experts in the field.  Particularly if an athlete is heading into their competitive season, the methods of conditioning used while rehabilitating injury should have three major considerations (1) picking an activity that will not exacerbate the injury (2) find an activity that utilizes the same major muscle groups used that mimics the athlete's sport activity and (3) provides cardiovascular fitness levels equal to that experienced during the athletes land based sport activity.

In the previous blog, I covered necessary means and guidelines for using aquatic therapy to adjust varying amounts of stress on the body while healing from injury.  One of the great aspects of using water during rehabilitation is the ability to perform functional activities that mimic the activities performed on land.  Obviously, running in the water will mimic the muscles used on land, only in a reduced weight bearing environment (see the previous blog).  Additionally, adding multidirectional movements in the water can help strengthen key areas of the athletes body including the "core".  Jumping activities, strength activities, and other resistance activities can be performed in the water under the direction of an appropriate licensed athletic health care professional to enhance athletic performance even while recovering from injury.

Maintaining appropriate conditioning levels in the water, however, requires special considerations to maintain high cardiovascular performance.  It is readily recognized in scientific sports medicine journals that maintaining maximal oxygen capacity is achievable at levels in water equal to land based training as long as the intensity of the cardiovascular exercise in the water is at a level that matches that land based training.  What most athletes don't realize is heart rate on land does not equal heart weight when submerged in water.  Due to the pressure of the water on the submerged body, there is an approximate 35% increase in heart mean stroke volume, a decrease in blood pressure, and an increase in cardiac output that provides more oxygenated blood to the working muscles (another reason to use water to help the healing process).  Due to these effects, target heart rates in water should be 17-20 beats per minute lower than on land to produce equivalent cardiovascular effects.  Athletes not aware of this nugget of information end up trying to exercise at heart rate values equal to land and become frustrated with water conditioning, finding they cannot get their heart rate up to land based levels in water without going anaerobic and fatigue out much too quickly.  Likwise, an athlete conditioning in water that does not monitor their heart rate values will fall into a "comfort zone" in the water at levels not sufficient enough to stimulate the desired cardiovascular effects and aerobic conditioning will suffer.

As an example of appropriate conditioning in the water, an athlete wanting to perform a long run at 155 beats per minute should run at an intensity level in water that is135-138 beats per minute for the same amount of time they would run on land and will have the same cardiovascular effect without traumatizing their injury.  Scientific studies have shown athletes can maintain their V02max values through water running as long as appropriate levels are achieved.  The literature is full of examples of athletes that have rehabilitated common overuse injuries of the lower extremities, conditioning only in deep water running for up to eight weeks without running on land and returned to championship levels of performance within days of being released to run on land.  It seems almost too easy to be true, but armed with the right information, training, and rehabilitation plan, it is more than possible.

As always, if you are going to train hard, you might as well train smart!  If not, injuries will occur or goals will never be achieved.  This is never more true than trying to train while injured.

Saturday, April 20, 2013

Using Effective Aquatic Therapy Techniques Can "Take A Load Off"

Repetitive pounding from weight bearing activities is a mechanism of injury for many sport related maladies.  Lower extremity overuse injuries plague the athletics world and occur from many factors (stay tuned for a later blog on this, it is quite interesting).  Tibial stress fractures, femoral stress fractures, metatarsal stress fractures, achilles tendonitis, chondromalacia, and patellar tendonitis are all common injuries that are impacted by repetitive loading of the lower extremity. 

Typically, patients with chronic stress related injuries will be instructed to remain active (but reduce or eliminate weight bearing activities), receive appropriate therapy on the injury, strengthen the affected area, and once healed, "gradually" move back into activity. Most Type A personality athletes take this as "get back to training as soon as I start to get a little relief from rest and therapy".  This is a natural response for competitive people but certainly not the best course of action to return from a significant stress related inevitably occurs. Elite athletes with stress related injuries try to avoid this mistake by incorporating specific methods of training during their recovery and rehabilitation.  By utilizing aquatic therapy as part of the rehabilitation program, top athletic health care professionals are able to manage injury restrictions, yet maintain or improve conditioning, strengthen the injured area, and formulate a measurable graduated return to full weight bearing to avoid re-injury after the athlete returns to competition. 

Gradual Return to Full Weight Bearing
For many stress related lower extremity injuries, reduction of weight bearing is necessary for the injury to heal, but total non-weight bearing is rarely prescribed.  Partial or restricted weight bearing is often chosen because the body needs this stimulation to propagate the healing process.  The effects of buoyancy in water allows performance of sport related activities in various levels of "measurable" weight bearing.  To estimate the percentage of weight bearing while in the water, there is a simple rule of thumb:

 0% Weight Bearing = Submerged but unable to touch the floor of the pool
10% Weight Bearing = Submerged in water up to the sternoclavicular joint (base of the neck)
25% Weight Bearing = Submerged in water up to the xiphoid process (just below the chest)
50% Weight Bearing = Submerged in water up to the ASIS (bones on the front of the hips)
(These are guidelines, exact weight bearing numbers depend on sex, body type, and body composition)

If needed, non-weight bearing activities can be performed in water deep enough the bottom of the pool can't be contacted.  The use of flotation devices on the torso allows the athlete to perform physical activities in the water in a non-weight bearing capacity. Commonly used flotation devices by top professionals are the AquaJogger, the Zero G Flotation Suits, and the WetVest.  Whatever device is chosen should provide enough buoyancy to allow the athlete to float neck deep in the water but maintain an upright running position.  All are effective and can be purchased online and are a great investment for the athlete relegated to water workouts for any extended period of time.

For those that don't have the luxury of elite athletes' access to a custom pool, there is no need to worry.  Utilization of  various depths of water in any pool can be performed to achieve these gradual increases in weight bearing.  Once cleared by an athletic health care professional to resume gradual weight bearing, start at the appropriately prescribed level in the pool and perform running activities at that depth.  As exercises are tolerated without exacerbation of symptoms, gradual movements into more shallow areas of the pool can occur to add more weight bearing.  As the level of weight bearing increases, steps must be taken to monitor for the return of any symptoms. Return of symptoms may indicate that progression has occurred too quickly, and a return to previously used deeper depths until the body has time to respond and adapt may be warranted.  Once running is performed at 50% weight bearing with no increase in symptoms, the athlete is normally ready to resume land based training (again increasing the workouts in a logical graded fashion over time).

Keeping the Pressure on the Injury
Hydrostatic pressure is the amount of pressure applied to the body while submerged in water.  The deeper the body, the more pressure is exerted.  (This is the cause of the sensation of the ears needing to "pop" when diving in deep water and the cause of some dangerous conditions in individuals who deep sea dive.)  What does this have to do with treating injuries?  Hydrostatic pressure can be utilized to control and reduce swelling at appropriate depths.  For every foot of depth in the water, 22.4 mmHg is equally exerted around the body part (remember mmHg are the units of pressure used in determining blood pressure). For the normal athlete standing in 5 feet of water, there will be 112 mmHg pressure exerted on the feet with gradually less pressure exerted on the legs as you approach the surface of the water. The average person's diastolic blood pressure is 80mmHg, so even if the water is warm at that depth, swelling will not occur.  In fact, hydrostatic pressure is significant enough that swelling will reduce due to the pressure and move upward into the body and removed through the lymph system.  This effect can be further enhanced with movement in the water since muscular contractions also assist in the movement of swelling.  Taking advantage of hydrostatic pressure is one of the "secrets" used to manage injuries of the foot, ankle, and knee by top level athletic health care professionals.

Something to Consider
Hydrostatic pressure at 5 feet of depth exceeds the pressure exerted by many popular compression and recovery devices, leading to the conclusion that walking in deep water may be a means to promote recovery after hard workouts (especially if the water is cool). Try it some time.  If you think it doesn't work consider this: have you ever noticed that after a long swim workout your clothes fit a little looser initially?  Fluid shifts cause minor changes in limb girth until gravity reverses its effects. So the consumer tip for the day is -- don't go shopping for pants immediately after swimming or you might be likely to go home a few days later to find they don't fit quite like they did in the store!

Are There Contraindications To Using Aquatic Therapy?
Aquatic therapy is not recommended in some instances including but not limited to:
1. Untreated infectious disease (the patient has a temperature/fever)
2. Open wounds or unhealed surgical incisions
3. Contagious skin diseases
4. Serious cardiac conditions (due to the centralization of blood flow caused by hydrostatic pressure)
Athletes with pulmonary conditions should not be submersed more than 85% due to the resistance of chest wall expansion by the water creating subsequent complications.  It is always wise to check with an athletic health care professional before commencing a program including aquatic therapy.

Helpful Hints and Tips to Make Aquatic Therapy Effective
1. For individuals who are going to be performing partial weight bearing water running activities in the pool for extended periods of time, footwear should be worn in the water.  Without footwear, blisters on the bottom of the feet will likely occur as the skin weakens and slippage on the bottom of the pool occurs.  An older pair of running shoes will suffice (make sure they are cleaned and free of dirt, etc).  Specialized water running shoes (AQx shoes) are available are very effective in protective the feet during water running.

 2. Weight bearing estimations assume a normal body position with the hands in the water at depths above the waist.  Moving the arms out of the water will increase weight bearing (many people will do this to move faster in the water due to better traction on the bottom of the pool from the increase in weight bearing) and will affect the amount of impact experienced during activity.

3. Exercise must be performed at an appropriate intensity to elicit the desired conditioning effect.  Specific guidelines for how to maintain conditioning levels, isolated injury strengthening, increasing core strength, and other hidden gems of aquatic therapy is the topic for the next blog!

Be well. Be informed. Be Active!

Friday, April 19, 2013

Just Because You Are Injured Doesn't Mean Your Season Is All Washed Up - Use Aquatic Therapy Correctly To Enhance Your Injury Recovery and Continue Toward A Maximal Performance

Each time I go to the local pool for a swim session, I see individuals in the deep water performing various activities to "get a workout while they are injured".  Many have taken to the water on the advice of a health care professional to participate in a subsititue activity to maintain conditioning while minimizing injury stress as they wait out the necessary healing process.  Unfortunately, in my conversations with some of these people, I learned that many leave the water with a healed injury only to find they have lost their previously hard-earned conditioning levels and regressed on their training plans due to a lack of understanding on how to take advantage of the water. 

Utilizing water for therapy has been described in literature for over 2,000 years.  Since Archimedes took his bath, medical professionals have progressed the understanding of how to effectively use water in injury management.  Many top athletic health care professionals have rediscovered the benefits of aquatic therapy in the past decade.  Medical journals have documented that training in an aquatic enviroment has beneficial effects for the injured athlete.  Aquatic therapy workouts provide an environment of reduced weight bearing, increased resistance to movement, circumferential progressive compression of submerged body parts, and the ability to exercise at levels to not only maintain, but improve cardiovascular conditioning.  The literature is scattered with case studies of athletes who have exercised in water during injury rehabilitation and have returned to land based activities with no drop in aerobic conditioning.  Why is it, then, that the average injured age-grouper athlete doesn't realize the same results with substitute water workouts as do elite level athletes?  The secret lies in a few of the particular physical properties of water and attention to specific execution of activities being performed to take advantage of those properties.  Armed with this information, the average injured age-grouper can utilize their local pool to get the same results as elite level athletes.

The rediscovery of the advantages of aquatic therapy has led many professional sports teams and universities to install specialized therapy pools with submerged treadmills, moving walls of water, and floors that change depth to take advantage of this great tool.   Athletic health care professionals are utilizing these pools for a variety of purposes:

(1) To reduce or eliminate the effects of gravity while performing an activity to mimic a land based activity (i.e. running).
(2) To perform activities at appropriate cardiovascular levels to achieve similar goals of  land based workouts.
(3) To utilize the pressure of water to reduce inflammation and edema in the lower extremities.
(4) To increase strength and mobility in specific areas and reduce the likelihood of reinjury once healed.

Fortunately, a specialized pool is not needed to perform an overwhelming majority of exercises used to achieve these goals.  The next few blogs will be dedicated to revealing secrets and introducing aquatic therapy activities and tips used by top athletic health care professionals to achieve optimal injury management and conditioning while injured.