Selected Issues in Illness and Injury Prevention

Mark E. Lavallee, MD, CSCS, FACSM February 2016

Director, York Hospital Sports Medicine Fellowship, York, PA Head Team Physician, Gettysburg College, Gettysburg, PA

Chairman, USA Weightlifting, Sports Medicine Society, Colorado Springs, CO Medical Director, International Weightlifting Federation, Masters World Championships, Budapest,

Hungary

Disclosure

• No financial relationships to disclosure

Topics to be Discussed

• John Hatzenbeuhler, MD • Return to Play

• ACSM Team Physician Consensus Statement

• Mark Lavallee, MD • Strength & Conditioning in

athletes • ACSM’s 2015 Position Statement

• Appropriate Prehospital Management of the Spine-Injured Athlete

• NATA’s August 2015 Position Statement

ACSM’s Team Doc and Strength & Conditioning in Athletes • Goal of Strength & Conditioning

• Optimize sport performance • Minimize risk of injury

• Multi-disciplinary team

representing the fields of • Neurology (Herring) • Sports Medicine (Putukian,

Poddar, Matusak, Franks, Boyajian-O’Neill)

• Orthopedics (Bergfeld, Kibler, Indelicato, Lowe, Stanton)

• To Accomplish this a Team Doctor should be involved in

• Strength & Conditioning principles • Sports-specific strength and

conditioning • Strength & Conditioning program

implementation • Injury & Illness implications of

strength and conditions • Selected current issues in strength

& conditioning.

ACSM’s Team Doc and Strength & Conditioning in Athletes • GOAL: help team doctor’s with

the role of exercise in conditioning.

• Nutrition/Supplements were outside the realm of this statement.

• NOT to be considered Std of Care

• Compiled with support/endorsement from:

• Amer Acad of Family Physicians • Amer Acad of Orthop Physicians • Amer Coll Sports Med • Amer Med Soc of Sports Med • Amer Orthop Soc for Sports Med • Amer Osteopath Acad of Sports

Med

• ABSENT: NSCA, NATA

Strength & Conditioning Principles

• Specificity • Designed to address athletes

specific sports needs.

• Prioritization • Depends on athlete, sport and

time • Not all elements of S&C should be

optimized at same time, rate or magnitude

• Progressive Overload • Provide increasing stimuli to improve

athletic • Strength • Power • Endurance

• Frequency-# of session over time period • Intensity-% of maximal fxn capacity • Duration-total time spent • Volume- total amount of exercise • Tempo- speed of perfromance

Strength & Conditioning Principles

• Strength, Power, & Endurance Training

• HEAVY Loads: >85% 1RM (< 6 reps) • LIGHT Loads: <60% 1RM (>12 reps) • Muscle hypertrophy

• Strength and power • Moderate loads 65%-85% 1RM (6-12

reps) • Power:

• Single best effort: 1-2 reps at 80-90% 1RM

• Aerobic & Anaerobic Conditioning

• Programs • Interval training -> SPRINTING • continuous training -> ENDURANCE

• Modes of Exercise • Running, cycling, swimming,

sprinting, etc. • MUST be specific to sport

Periodization

• Periodization Cycles • MACROCYCLE (Long-length)

• 1 year/ competitive season • MESOCYCLE (Medium-length)

• 1-6 months • MICROCYCLE (Short-length)

• 1-4 weeks

• Types of Periodization Programs • Classical (or Linear):

• For sports with limited competitive season and well-define off-season

• Football, Weightlifting, Pole Vaulting • Used more for elite in sport, not

novice • Undulating:

• For sports with LONG competitive seasons, multiple competitions, year round practices

• Tennis • More intense around Microcycle

Strength and Conditioning Program Variables

• Exercise Order • Large vs. Small muscles • Single vs. Multi-joint exercise • Cardio vs. Strength vs. stretch

• Exercise Selection • Resistance training (free weights,

machines, band, body weight) • Sprint or Endurance training • Plyometrics • Agility/ Proprioception

• Load • Amt of resistance per rep per set

• Muscle Action • Concentric: Tension with muscle SHORTENS • Eccentric: Tension with muscle LENGTHENS • Isomteric: Tension with NO change in muscle

• Repetition Speed

• SLOW: strength development • FAST: Power development

• Rest Periods

• Amt of rest between sets, exercises or reps.

Active Rest and Recovery

• Conditioning Modification: Special Populations

• YOUTH: • S&C is NOT associated with injury if

performed correctly!! • Strength gains in pre-puberty due to

RECRUITMENT & SYNCHRONIZATION , not hypertrophy

• Periodization: 2-3 months OFF/yr • Watch for adult-sized equipment • Adult supervision crucial • Care in using Heavy weight lifting

(1RM) and endurance training in skeletally immature CJ Cummings, 15yo breaking American record of 175 kg C&J at

69kg (World Record: 176Kg, he attempted and missed) Dec 4th, 2015, USAW American Open, Reno, NV

Active Rest and Recovery

• Conditioning Modification: Special Populations

• FEMALE ATHLETES • Modifications during pregnancy • Post-menopausal concerns • Those in hypo-estrogenic state • Comprehensive S&C important

Cheryl Haworth 2 times Oly

Active Rest and Recovery

• MULTISPORT ATHLETES • Overlapping Seasons • Maintain general athletic fitness

base • Active Rest and Recovery • When preparing for 2 sports at

once • Conditioning injuries • Overtraining

• ATHLETES W/ PHYSICAL & INTELLECTUAL CHALLENGES

• Benefit from Sports participation • Involve modifications of S&C • Adaptive sports equipment,

prosthetics, • Mitigate injury • Most can participate given right

accommodations • Special medical concerns need to

be addressed

Bo Jackson- MLB and NFL

Sport-Specific Strength & Conditioning

• Components • Evaluation to determine fitness

profile and purpose of S&C program

• Periodization program to address inherent demands of sport

• Evaluation process to determine efficacy of conditioning program

Objectives: Sport-Specific Strength & Conditioning

• General Athletic Fitness • Total body flexibility • Total Body muscular strength, power,

& endurance • Aerobic/Anaerobic capacity • Body Composition • Psychological well-being

• Sports-Specific Athletic Fitness • Physiologic parameters • Biomechanical actions • Neuromuscular control • Inherent demands of sport

• Sport-Specific Performance/Skills • Optimal goal/performance • Refinement of unique training and skill

acquisition

Program Implementation

• OFF-SEASON • Length of OFF season • Planned Participation in multiple sports • Status of physical/psychological base • Rehab needs for injuries/illnesses • Sports-Specific Goals • Injury Prevention

• FFMS (Functional Movement Screening) • Y-Balance • Shoulder girdle strength- Overhead athletes • Warm-up/cool-down (FIFA 11+)

Program Implementation

• PRE-SEASON • Length of Pre-season • Intensity of pre-season • No. of practice per week • Status of Physical/ Psychological base • Ongoing rehab needs • Environmental issues (Heat/Cold, Altitude) • Weight Management issues

• Weight goals and weight-restricted sports

Program Implementation

• IN-SEASON • Length of competitive season • Intensity of season • Number of Practice/ games per week • Status of Physical & Psychological base • Ongoing or new injuries • RTP criteria • Ongoing weight management issues.

Injury & Illness Implications of Strength & Conditioning • MSK

• Overload Injury • Traumatic Injury

• MEDICAL ISSUES • Overtraining Syndrome • Female Athlete Triad • Dehydration • Exertional Headache

• LIFE-THREATENING • Exertional Rhabdomyolysis • Exertional Sickling • Exertional Heat Stroke • Sudden Cardiac Rest

Current Issues in Strength & Conditioning `

• Eccentric Hamstring Training • Rehab AND injury risk reduction

• Some commercial High Intensity programs may not include all necessary components recommended- so less valuable

• Training with variety of equipment (kettlebells, etc) present own injury pattern-risk

• Meeting training goals must include balance diet and adequate sleep.

• Adequate sleep is critical to maximize performance

• Conditioning should NEVER be used to punish, bully, or harass an athlete.

ESSENTIAL that the Team Physician should understand…. • Strength & conditioning

principles and programs • Sport- and athlete-specific issues

for rehab and injury prevention • Role of S&C program as it is used

for: • Improved sports performance • Decreased injury risk

• Injuries, illness resulting from S&C

• Importance of communication within the Athletic Care Network

• Coach, ATC, PT, parents, AD

• Aware or involved in development of Emergency Action Plan

Kendrick Farris, gold medialist, 2015 Pan Am Games, Toronto, CAN

DESIRABLE that Team Physician be involved:

• Comprehensive knowledge of the sport

• Ongoing assessment of physical and psychological aspects of S&C.

• The implementation of a S&C curriculum

• Education of athletes, parents, coaches, ATC about importance of S&C

• Integration od S&Cprogram for injury and illness rehab

• Development of strategies to limit illness/injury risks involved in S&C

• Heat Stroke • Rhabdomyolysis

Appropriate Prehospital Management of the Spine-Injured Athlete

• GOAL: to re-visit 1998 document and update

• Released on June 24th, 2015 • Published on August 5th, 2015 • 1 Week BEFORE Football preseason

started

NATA’s On Field Assessment (Paradigm Shift)

• Continue with on field assessment of injured athlete

• If unconscious/ unresponsive • If suspect spinal cord injury

• 1998 • “package” athlete with helmet and

pads on send to ER

• 2015 • Must remove hemlet and Pads

BEFORE transport to ER

Key Points

• Traumatic Spinal Cord Injury (SCI) is devastating and merits concerted focus due high morbidity/mortality

• 12,500 new cases a year in USA • 9% due to sports or recreational

activities • Athlete with suspected SCI present

unique challenge different from general population (i.e. equipment)

• Sports Med Team must work together efficiently, in concert

• 14 Recommendations

Recommendations

• Recommendation #1 • Each Athletic training program

have an EAP with local EMS • Essential to provide education AND

training • ATC on site for all sporting events

• Recommendation #2 • Sports Med Team conducts a

“Time-Out” before events to reviewed

Recommendations

• Recommendations #3: • Proper assessment of spine

injured athletes-patient to active EAP

• Recommendation #4: • Protective athletic equipment

should be removed PRIOR to transport to ER

Recommendations

• Recommendation #5: • Equipment removal should be

performed by at least three rescuers trained and experienced

• (if <3 providers, remove equipment at earliest time)

• Recommendation #6: • Sports Med team needsto be

familiar with varied different protective equipment for different sports.

Recommendations

• Recommendations #7: • Rigid cervical Stabilization device

should be applied PRIOR to transport

• Recommendation #8: • Spine-injured athlete should be

transported using a rigid immobilization device (i.e. back board)

Recommendations

• Recommendation #9: • Minimize spinal motion when

moving athlete from field to transport vehicle.

• Recommendation #10: • Transport plan be developed

PRIOR to start of any athletic practice or competition

Recommendations

• Recommendation #11: • Athlete should be transported to a

hospital that can deliver immediate, definitive care for these types of injuries

• Recommendation #12: • Prevention of spine injuries in athletics be a

priority Need collaboration w/ Sports Med team, Coaches, Athletes.

Recommendations

• Recommendation #13: • Medical Team must be up-to-date

on research and local/national regulations to ensure “best Practices.”

• Recommendation #14: • Future research continue to investigate the

efficacy of devices used to provide spinal motion restriction

Participating Organizations

• Amer Acad of Family Physicians • Amer Acad of Neurology • Amer Acad of Orthoped Surgeons • Amer Acad of Pediatrics • Amer College of Emerg Physicians • Amer College of Sports Medicine • Amer College of Surgeons • AMSSM • Amer Orthop Soc for Sports Med

• Canadian Athletic Therap Assoc • College Athletic Trainers Soc • Nat Assoc of EMS Physicians • Nat Assoc of EMTS • Nat Assoc of Intercolleg Athletics • Nat Assoc of State EMS officials • Nat Collegiate Athletic Assoc • Nat Fed of State High School Assoc • North Amer Spine Soc • Prof Football Athletic Trainers Soc • U.S. Olympic Committee

ABSENT: ABIM, AOASM

References

• Herring, SA, et. al., “The Team Physician and Strength and Conditioning of athletes for Sports: A Consensus Statement,” MSSE, 2015, 1(32), pp 440-445.

• NATA updated document on “Appropriate Prehospital Management of the Spine-Injured Athlete Updated from 1998 document), Executive Summary, released August 5th, 2015, www.NATA.org