ICSC09 Transcripts Culture Diversity

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English Direct Download PDF ICSC09 _Section 1_Gender Diversity

ICSC Culture Diversity Module 09
ICSC09 _Section 1 Gender Diversity
Instructor: Henry Pollard
Video Lesson: 34:56

My name is Doctor Henry Pollard. I am coming to you today, to present a unit in the cultural diversity section of the ICSC program. Today’s talk will be about gender issues in sports prior to. I would just like to acknowledge the content here has been sourced from multiple providers there and they are all listed for your information moving forward. Here is a little bit of background on me. I have been involved with FICS for the best part of 20 years. Primarily in the research area where I am the chair and also in the education section.

We are going to go over today, a general overview of gender issues in sports and look to try to understand common gender equality issues and gain some knowledge on how to use gender-neutral language and promote inclusiveness. I specifically will cover challenges in getting gender equality, biological differences in the genders, injury differences, performance differences, and how we might go about addressing some of these things in a workable fashion, not only within the sporting endeavor but also in the wider community.

It is all about is gender-affirming care, which is a supportive form of healthcare. It consists of an array of services that can include medical, surgical, mental health, and other non-medical services for transgender and nonbinary people. While some of this talk is about transgendered folk. Some of the issues just simply exist between what we will refer to in the future as the biological sexes. But as well here shortly, it goes much further than that. Research demonstrates that gender-affirming care improves the mental health and overall well-being of gender-diverse children, adolescents, and adults, which is why it’s becoming a key feature now in health care generally and increasingly in school.

But as we will see shortly, with that comes a few little issues that are going to need to be addressed moving forward. What is gender neutrality? It is the idea that gender should play absolutely no part in social roles and structures, gender identity, official policies, language, and other social constructions or institutions. It aims to abolish the idea that genders can play only certain roles and it propagates the idea that instances of discrimination can be minimized if not utilized completely by forwarding the idea that gender has no place in the assignment of social roles. Now sport plays such a huge part in our social well-being and our social presence that, you know, it is just timely that these issues have been raised and are being addressed within the environment of sport and the way sport operates.

Sports Equity is about fairness in sport, equality of access, recognizing inequalities, and most importantly, taking steps to address them. Which is why we’re having this talk today. It is about changing the culture and the structure of sport to ensure that it becomes equally accessible to everyone in society and that is probably the bottom line for this talk today.

You may be getting a little bit of a flair that there are some legal ramifications to all of this and there are making distinctions and or treating unfairly a specific group by definition discrimination. Giving one particular group opportunities which are not available to all groups is another discrimination that can be an opinion or an attitude or the way we display dislike towards a group or an individual and this can be on the basis of gender, skin color, race, ethnicity or other factors.

Then obviously acting upon prejudice is also a form of discrimination. This particular issue with gender ties nicely into the broader concept of cultural differences, which this unit in the ICSC represents. I am one of the heads of, where is this the head of the research for FICS and someone who has done a fair bit of research, I have just come across this recently that some of the biggest journals in the world now are now mandating a requirement for sex and gender reporting within research that is published in the journals. This is another example of how these ideas and being enacted by various quite established groups to create change moving forward.

I think that was a good one there that just came across my desk recently, so, excuse me, there are legal and etiquette issues here. Let’s start having a look at some of that, you know, when you were born, a doctor or clinician assigned you the male or female label based on essentially a look at your genitalia. Now, sex designation is just not that simple. Overwhelming evidence shows that sex is not binary. There isn’t just the male and the female, and it does not capture complex biological, anatomical, and chromosomal variations that occur within the human body.

Because of these facts, there is a growing movement to remove sex designation from birth certificates, although that is meeting with different states of approval in various places around the world. Variations, just to provide a little bit of information now on the scope of these issues. Variations in genital anatomy happen more frequently than you might think. It’s point 1 to point 2 of births annually, this is U.S data, but it is similar in Australia and probably other places as well.

Other sex traits don’t necessarily help either. Doctors examining the reproductive organs find people with both a vagina and testes and those born without any gonads. Even karyotyping which is a lab procedure used since the 1950s to evaluate an individual number and type of chromosomes really doesn’t help either. Just to mention a few Turner Syndrome is a person born with a single X chromosome. Klinefelter syndrome is a person born with a combination of XXY chromosomes, and there are many others as well, so once again, there is no simple answer for how we describe all of this.

When we are looking at human diversity, the concept of binary categories of “male” and “female” are essentially incomplete and inaccurate. Sex designation rather than a two-size fit all is actually on a spectrum. Up to 1.7 percent of the U.S population which is more than 5 million Americans have anatomy and physiology that present intersects traits. That came across as a very high number to me and certainly something which needs to be represented in the institutions of our society. Those with intersex traits who are assigned at birth to be female, or male can experience medical care that harms them both physically and psychologically. From that to bring it back to the perspective of sport, the International Olympic Committee uses cut-offs on hormone levels to determine who plays in women’s sports.

As a result, some of these athletes have been banned from participation. Now, we are going to talk a little bit further about that because again it is not as simple when we get up to the top levels. Let us look at diversity. Governments around the world have begun to acknowledge this sex diversity. Medicine is also changing with this chance. Society at large has been essentially slow to move beyond the use of binary categories and the evidence shows that using male and female as the only option on birth certificates is not consistent with scientific reality, so it is not an evidence-based concept.

Let us talk about a few key definitions now that link at the bottom there has an extensive list of terms that are used in this discussion, which you can refer to at a later time, but biological sex is the binary involvement that includes chromosomal, hormonal, and anatomical components. The gender or gender role refers to societal attitudes and behaviors associated with the two sexes, it is learned context-specific varies from one culture to another and I would also say religious as well and is dynamic and changeable.

Gender identity on the other hand refers to a person’s understanding and experience of their own gender. Gender bias is the inclination or prejudice for against one group or person which may be unconscious. Intersexed individuals have ambiguous genital anatomy, think the spectrum again. People with intersex variation may or may not identify as male or female identify as both or between, or neither genders and at different times. Transsexuals are raised as one sex while emotionally identifying with the other sex. Transgendered describes an identity adopted by those who are uncomfortable with the gender of their birth.

There are a lot of definitions here that are used commonly in the discussion of gender issues and maybe it will be worth looking some of those up. All of that leads to stereotypes and stereotyping which are typically based on gender roles and societal norms. Gender roles and norms are never neutral or static they evolve. They are usually negative, contribute to gender-based discrimination, determine expectations for women and men in fairly narrow categories, and predetermine control over resources, and allocation which is where a lot of the discrimination actually lies.

What are the causes of gender problems? Poverty, illiteracy, patriarchal societal values, social customs, beliefs and practices, and a lack of awareness among women. That little picture there is I think a good example here where Dad pushing a child on a swing gets the scripter, he is a cool dad he is out spending time but if the female or the mother is doing the same thing, that are not quite get the same positive, they just being a mom, that is what moms do. There is an unfair stereotype being applied there.

Now some of the challenges that arise because of inequality that come from the stereotyping include inferior access to education, employment, and remuneration. There is job segregation, there are legal protections, bodily autonomy, poor medical care, religious freedom, and outdated societal customs, beliefs, and practices. That is a fairly all-encompassing description of limitations that come about from inequality and the acts thereof.

We are talking about human rights here. Every human is entitled to live with dignity and without fear, it is essential for development, poverty, reduction, and human progress in the broadest sense. Whilst that may not be something that is top of mind when it comes to First World Nations, it certainly is in others, in sports crosses all of these boundaries and thus we need to be aware of those. Yeah, gender equality is a concept, which is an important one and essentially it is equal ease of access to resources and opportunity. Equal access to economic outcomes, decision-making, and remuneration. The inclusion into societal political, administrative, legal, economic, sporting, and other structures and functions of society.

Now, I presented an example here, which was one I recalled when I was asked to do this talk, so, I went and found out a little bit about her, about the South African athlete Caster Semenya. This was published by Miss Peale in the globe, a couple of years back and the bait in sports over the definition of womanhood is paternalistic and hypocritical. Just to give you a bit of a background of this athlete. Agenda test revealed she had a y chromosome, which normally makes a person mighty. She also had complete androgen insensitivity syndrome or CAIS, which prevented her body from responding properly to testosterone and caused her to develop as a woman. The Spanish athletic Federation got her test results in 96, just before a major competition that would have set her up for a run at the Olympics.

Though she won the 60-meter hurdles, the Federation declared her ineligible for the 1988 summer games and soul. The international Olympic Committee has struggled with cases like this variously using her patterns of chromosomes, individual genes, and other factors in their long-running attempt to distinguish men from women. All these tests have been discarded, so, that was a very high-profile example of the Angst that this individual went through, and basically her removal from what she did. Now the key point here in another tool in an organization Intersex International Australia was that these athletes are not doping, they haven’t cheated and they simply wish to compete as they were born and raised and I think that is a key point here, that it is not their fault what is happening, and so, we are going to move further down this discussion now to talk about what are the actual differences.

From the perspective of the female, we are all aware of the increase in estrogen relaxants and reduce testosterone. Probably the main issue there in the physiological effects is the increased potential ligamentous, laxity that occurs there which has been associated with the increased injury rate. From the sort of cardiopulmonary system, you know essentially males have it better, in that regard, there is reduced stroke volume, cut out the output you know, etc. VO2max for the female when compared to the male. Then when we go through to the musculoskeletal system, there are big differences, females are not as strong. They don’t have a greater speed of contraction, they have increased resistance to fatigue, which is the plus side I suppose, they have reduced bone strength, and they have improved through my wreck. All these factors here may or may not relate to injury difference.

Most of this is essentially just due to body structure and most of the differences are sport specific rather than sex specific with the exception of probably ligamentous laxity and some biomechanical factors such as a wider pelvis in a female which changes angles and biomechanical factors that are occurring in the lower limb. They are probably associated with injury but otherwise we are looking at just simply that one human, maybe a larger human than another human, so we will talk about that.

The body mass differences and here I went to the world rugby, they have a paper on transgender issues, and it was about the mass differences. In Rugby, the international level men’s players are 40 percent heavier than typical female plates. That is a huge amount, amongst the four, the heaviest one percent of women players are smaller than the typical forward. The heaviest one percent of women’s backs are smaller than the typical men’s backs and the lightest one percent of men’s forwards are approximately equal in mass to the heaviest ten percent of women’s forwards.

We are dealing with much bigger and larger humans here. This is got real implications for injury because if we are now going to put forward an individual who is transitioning from say a male identity to a female. This person is a larger person than the others that they’re likely to encounter, and that has implications for injury because the masses are the largest the accelerations are the largest. Then, for example, the potential for concussion and head injury is greater because the forces are greater on a smaller rival. It is not as simple as men playing men, and females playing females, it is much broader.

Looking at the performance differences which I found quite interesting through a number of different sports, as you review the functional differences there and when we are talking about strength, it is above 50 percent for most of it, punching power is 160 percent different. When we start looking at performance differences for various swimming, and rowing, okay, their lower level is around ten or so. Then tennis, golf, and cricket in a twenty-odd percent. Then when we start talking about the big Power Sports like baseball pitching, powerlifting, rugby scrum forces the differences can be quite substantial. This is raising an issue that the categorization is not the only factor here and how that occurs.

If we look at sex-based differences in sports. On the left there we have got swimming speed skating, cycling, running, Ironman Triathlon, and jumping sports. You can see anywhere from five to almost 20 percent differences in sex-based differences. For those that are transitioning from one category to another regardless of direction, what we not dealing with here is a Level Playing Field and that is where the problems lied.

This is as I said this is where this all gets started to get interesting. This slide here presents information on transgendered women who have undergone at least 12 months of suppression of testosterone, and then they have been retested to assess their retained advantage over females. As you can see there, those retained advantages are substantial. We are talking anywhere from 10 to 40 percent improvements or not. They would make improvements, but 10 to 40 percent differences in strength and other variables, so, it comes back down now to the concept of fairness and that is a legal doctrine, law, justice, and fairness.

 

Whilst it may be possible to place people in different categories, it then becomes an issue. Is it fair for everyone to do so? This is really the big issue I think that is facing the OIC and other international groups at the moment because of the potential for injury and lawsuits that come thereafter and all of these types of things. This is by no means a simple solution, but I introduced this concept to you here simply to make the point that I think that this will evolve in the next 10 to 20 years and categories will probably evolve for persons in different categories in between the two binary ones. But this is very much what is this space scenario.

Let us have a look at something that now becomes a little bit more, what can we do about all of this? In 2007 International Olympic Committee consensus statement on sexual harassment and abuse in sport described sexual harassment and abuse as a range of behaviors that might include sexually suggestive conversation, jokes innuendo, and similar acts that are offensive degrading, or unwanted such acts actions may not always set specifically into a legal context but can form sexual harassment and bullying.

Then we move on to homophobic abuse, another form of harassment. Homophobic comments and slurs range of negative attitudes and feelings towards homosexuality or people or being lesbian, gay, bisexual, or transgender, it can be expressed as antipathy, contempt, prejudice, aversion or hatred may be based on irrational fears, and usually is, and is sometimes related to religious or cultural beliefs. Either way, it is still abuse.

Then there is an even probably trickier area, which is then probably beyond the scope of this talk. But I throw it in there for completion and this is the hormonal treatment of young people. Social gender transitioning is a highly specialized area for medical practitioners and it is not something that probably a thorough party should enter into other than to be supportive of the individual. Prescription of puberty blockers and other things, gender reassignment surgery is probably not a treatment option for most based on the currently available evidence. I am not going to go into that too much other than the say it is an issue and particularly in children.

We then bring up other issues and this is the term punishment which may have legal ramifications. The use of punishment particularly in children’s sports may have sexual abuse implications, physical tasks, and/or abusive language used as punishment in a sporting environment may in some cases be interpreted as abuse or harassment. No one would sanction a coach for striking an athlete, there is some uncertainty about what constitutes psychological punishment. This is another target territory essentially in the legal area. I hope that we are forming the opinion that this is not quite as black and white as what a lot of us felt, it maybe is and that there are a lot of subtleties to this discussion that requires some informed opinion as opposed to just an opinion.

Let’s look at some common issues from a practical perspective. Are there adequate toilets, and change rooms? The uniform and dress standards, what about it? Records, logins, and emails now should address name changes that are legal or otherwise medical status, sick leave, and co-worker reactions. Most people are not well-versed in these concepts and often speak out of turn, develop standard responses, and encourage staff to raise concerns privately.

As an organization, FICS introduced this talk to basically provide understanding and recognition of the problem and this is an important sort of moving forward. The concept of confidentiality is key with transgendered athletes or really anyone for that matter and speaking out of turn about any aspect of this is strongly discouraged and maybe illegal and likely it is something to note moving forward. Moving a person to a different position in an organization where not requested may be seen as unfavourable treatment.

 

Requiring a person to use a toilet or change room that does not match their gender is gender identity discrimination by definition. Refusing time off for medical appointments could be impairment or gender identity discrimination. Refusing to organize a name change as the person’s request on personal files, emails, IDs, patient files, etcetera could be indirect discrimination. I hope you are getting the feeling here that whilst from a societal point of view and our sports point of view, we should be doing the right thing but increasingly now doing the wrong thing is starting to attract legal attention and which if for no other reason is probably a good reason why you should not be doing that sort of thing.

It was an interesting paper I found that suggested, this was a study on perpetrators of gender-based and sexual harassment in Canadian orthopedic surgeons. Now, when you look down the list there are highlighted two points. The two biggest areas of harassment were from peers and were from patients. This is a big problem right across the spectrum of medicine and it comes from patients other Allied Health Care, peers, supervisors, underlings, and the whole lot. This is a societal problem, which is basically being manifest in medicine and so we as part of that group need to take affirmative action to address some of those issues.

Hints the talk, and that starts with language, language is important, changing gender-insensitive language can be modified to be more sensitive. A policeman is a police officer. A businessman is a business person or manager or executive. A cameraman is a camera crew. Chairman is a chairperson. A cleaning lady is a cleaner or a housekeeper and so many of these gender-insensitive terms have a real stigma associated with them, and whilst they may have become habit through just repetitive use over time. It is something that we should think about and look to change in our language.

What can we do about all of this? Recognition is one thing, but action where we begin to incorporate these positive approaches and then begin to take steps to remove negative ones. Overtly not just covertly is important and then ultimately, we hope to get some transformation in the way we all behave and interact.

How can we help? Develop a shared vision and consensus on gender equality objectives. Involve all relevant stakeholders in dialogue on objectives and activities. Make long-term commitments to stakeholders and related activities, assess and strengthen stakeholder capacity for gender responsive and participatory analysis, planning and implementation.

For example, FICS fosters diversity, inclusion, and respect in the workplace. We recognize, appreciate, and utilize the unique insights, perspectives, and backgrounds of each staff, practitioner, and student member including gender-diverse employees, participants, and volunteers. That is an example of how we want to make a positive statement about this that will be reflected within the organization of FICS moving forward.

How can we be a bit more equitable with all of this? We need visible inclusion policies, in the previous slide. Then we need to on our forms. We need to describe nonbinary terms and that should be an option moving forward. Job interviews and other participation should be open to all persons. Managing workplace transitions to affirmation, appoint a case manager to assist. You may also require a support person. What questions to ask and what options to discuss, right?

Pronouns are important, so this is the language itself and you will notice at the start of my talk here that I have listed my pronoun as his him. The act of making assumptions even if correct sends a potentially harmful message, it can be offensive or harassing to guess someone’s pronouns and refer to them using these pronouns, if that is not how they want to be known. If you don’t know just simply ask politely if you get it wrong, so, I’m sorry, and then just ask how would you like to be known. It is a common courtesy more than anything that we may need to make this a little more systematic and then make your own pronouns known to emphasize someone that is making theirs known. There is more information on the use of pronouns at that link. All those links there for you to view.

Information for colleagues, names, and pronouns ask if you’re wrong apologize and get it right next time. What about the past, asked how they would like to be described, names and pronouns don’t assume. Now, what is not a cool question to ask, right? You do not ask about personal anatomy in any way, shape, or form. You would not do that anyway and should not do it for this particular group, whether the person has or intends to have surgery, whether the person is on hormone treatment or not, the person’s sexuality, none of which, it is all personal information and if the individual wishes to share it, they will. Otherwise do not ask about it, do not make jokes, and do not gossip.

A lot of this is just common sense that a person received the same treatment when transitioning, it is business as usual, if they want to change something for a particular reason, they will tell you and that is okay. I think it is just treating everyone like an equal and being respectful and in which case, I think everybody gets along famously.

I will just finish up the talk by saying that change takes time and work. And we do have to get out of our own old habits, which may initially be perceived as being not particularly welcome in some circles, but that is okay. We need to persist with that and begin to change our IDs, and then slowly move towards integrating the new IDs into the establishment IDs, and once that actually begins to happen, we will actually arrive at a new status, which will be more inclusive and more helpful for all involved.

At this time, I would just like to thank you for your attention and good luck with the future.

[END]

 

English Direct Download PDF ICSC09 _Section 2_Senior Athlete

ICSC Culture Diversity Module 09
ICSC09 _Section 2 Senior Athlete
Instructor: Anne Sorrentino
Video Lesson: 55:40

My name is Dr. Anne Sorrentino, I am a Sports Chiropractic Diplomate with the American Chiropractic Board of Sports Physicians and a member of FICS. I am here to present special considerations in specific athletic groupings, the senior athlete.

If we define special populations, they are by definition, a group that requires more Healthcare Services or specialized Healthcare Services than the average person. The greater need for healthcare services among those populations is generally more costly to the system. We can spend some time understanding what their healthcare needs are. We can perhaps reduce some of the extra costs and also give them a more productive life.

There are several categories considered special populations; pediatric/adolescent, the female athlete, differently abled and then there are also special diseases in disease states and sports. We are covering what is officially titled the geriatric athlete, but I got to be honest with you, there is no way I am going to use that term with me ever, I renamed it, the Senior Athlete.

Welcome to being a Senior Athlete or using that term, your patients will appreciate it. When we cover the guidelines for this presentation, they are based loosely on the CCSP Program Guidelines from the ACBSP, but I will be covering some international information. We are going to cover psychology and motivation, exercise with aging, underlying systemic disease, and some exercise prescriptions.

Geriatric refers basically to medical care for older adults, but the age group is not easily defined. “Older” is a term that is preferred over the elderly, but they are both imprecise titles. When I started doing all my research for international situations, the Aging Athlete is basically what was discussed.

When we talk about the Aging Athlete or the Senior Athlete, we are referring to anyone that is over 65 years, that is usually the number used. But most people don’t even need geriatric expertise before they are 70 or 75 or some even 80. The mean age of those that are more than 65 is now more than 75 years of age. We have a lot more people that are in their 60s, 65 age group, than those above 75. We are seeing more and more people that are exceeding the 80s and the 85s.

But American Association of Retired Persons started sending invitations to join at age 50. At this point, what is the age? We looked at the United Nations and the global population aged 60 or over is about 1 billion out of the 7 billion people on this planet. In 1980, it was only 382 million. But when we look at what’s going to happen in 2050, which is only about 40 years from now, it is going to be 2.1 billion, look at the exponential growth.

The number of people aged 65 years or older in 2011 was 11.2% of the population and that will double when we get to 2040, which is in 50 years and they still be alive too. At this point, we are looking at how Healthcare is evolved, how science has evolved, and how things have evolved that are keeping us alive longer. Because in 1914, a girl born in England only had a 1% chance of living to 100. Now, fast-forward 100 years, and there’s a 50% chance of living to more than 105. I don’t know if I want to be around that long, but the possibility is there.

Let us see what the psychology and motivation are to have the Senior Athlete participate in physical activity. When we start to look at our demographics, we see a higher prevalence of men working out than women, but as they age, it starts to decline. The numbers will stay a little higher with higher education and a higher income. Those that are widowed start to come out and maybe stop going out and becoming physically active.

 White non-Hispanic and Asian Pacific Islanders are more likely to exercise than Black non-Hispanic. I see a lot of elderly Asian Pacific Islanders that become runners, and they are populating some of the races. But ageism is the third greatest prejudice. Ageism is very simple making the practice of unsubstantiated judgments.

Start to rethink those judgments because when you are looking at someone’s age and already having a preconceived notion, as to what that person is going to be like based on the chronological age, I still remember when my mother turned 80 and she said I don’t want anybody to know that I am 80. Did she look 80? No. But she was, I don’t want anyone to know that because they instantly give you a look and they sort of look down on you as if you don’t know anything and you are useless and there’s nothing for you to do.

We see that in healthcare, yet there are people that are so productive, right up until the day they die. Brett White died just shy of her 100 birthday, Tony Bennett is still singing. We have these clinical decisions that we make as Healthcare practitioners, not based on their health status, but on their age. We all accept that there are things were not going to be able to do with our bodies as we age to a certain point.

Our brain is still 14, we are still functioning and knowing that we can do something, maybe not this fast, maybe not as hard, but we can still give it a good go. Another barrier we are seeing toward physical activity is the cost. It cost to go to a gym, to buy exercise equipment, and it costs to have a personal trainer or join an exercise class. There are some physical limitations and the one thing that is getting good in all the exercise classes is they are doing progressions and regressions.

They are training the exercise instructors to be able to level up or level down. If you cannot do a push-up on two hands, drop down to your knees. If you cannot go all the way down, do it off a table, do it off of a chair. They are starting to make these exercises for more doable for every age group and every ability.

Another barrier is a lack of motivation, which we all have sometimes? You wake up, it is a dreary rainy day, and the last thing you want to do is get up and go for a run or even go for a walk. Maybe you will do it later in the day, but then you get into something else. Those motivation factors can crush any of us, it is not just the older ages. But this is a very important point to look at this at the bottom.

Older patients have lower expectations of their health status. They believe they are unable to play, and they walk past the park and watch a bunch of people running around playing soccer or football and think I used to do that, but I cannot do that anymore. How do we get through those barriers? We must look at the lack of motivation and what levers we need to facilitate change. We must look at what a person thinks are true, what a person thinks are good, how a person does things, and the person’s talents or ability.

Maybe they cannot raise their arm straight up in the air and have to do it a little slower, moving it in a certain way. Maybe they cannot get it up and they can only go here. We must look at what their ability is, and where their limitations are and come up with a way to make it work.

The athlete must perceive a benefit. It can be qualitative, it can be quantitative. It can be I walked twice today, it could be I made it back and forth to the corner, I went down to get my mail and then moving a little further. My mother just had a knee replacement and she wants to go, go, go. She has to accept what she can do today, and tomorrow will be better than today and the next day.

 We have to see that build-up, and the athlete has to see that and be able to look back to yesterday going, “Oh wait, I could only walk down to the driveway. Now I walked up to the second house up the block.” Monitoring changes in those measurable indicators are phenomenal, just for their healthcare, whether their glucose is going down because of your testing through a glucometer. Their BMI, we have scales that now will them how they are starting to lower their BMIs.

DEXA scans where they are starting to see that their osteoporosis may not be declining and it is starting to get a little better with their bone density. Blood pressure going down, balanced tests, smartwatches. Someone told me a joke “What is the smartest thing about a human?” I said their smartphone? These phones are telling us everything. People are tapping them and looking at what their oxygen intake is.

But some of them don’t like technology, so they keep a diary to see their progress. Paper and pencil still work, and I do love my paper and pencil. Approximately 10% of older adults participate in regular physical activity for 30 or more minutes, five times a week. This is the common recommendation from the Centers for Disease Control and the CDC in the United States. Approximately, 35 to 45% participate in minimal activity.

It is interesting when you ask what their physical activity is because there was an elderly gentleman at my husband’s office, and I was covering for my husband while he was away. I remember saying to this gentleman, I said, “You walk?” He was, “Oh, yes I walk every day.” I said, “Oh, how far do you walk?” He was, “Well, I walk up to the second floor of my house”. I went, “Okay.” He replied, “Well, my wife’s on oxygen so I have to go up to the second floor to smoke a cigarette”. I went, “Okay”. Did I judge? I just said, “Okay”.

Then I had the other woman who said, “Oh I walk.” I said, “Oh, how far do you walk?” She was, “I don’t really walk”. Sometimes making your patient accountable and then you have to decide how are you going to inspire them to get up on some of this activity? Because when you ask what that minimal activity is, the two most likely answers are, are they walking or gardening? I am like, “Gardening is your physical activity, well, you have never seen me, garden?” “Okay, I have not”.

I remember Roy Decker who has long passed, who would come in every July because he fought the rototiller while he was gardening, his field of one acre. That’s gardening. You have to define what their activity is. Don’t hesitate to ask because older adults tend to be less active than other age groups for many reasons. But if I have to say the number one, they have disorders that are limiting their movement and that is one of the number one factors that we see as barriers.

The athlete comes in and then you have different people come in to see you. Some have been physically active throughout their life. Let us go back and talk about my mom because I still remember 1965 her standing in front of the television holding onto the chair doing abduction exercises with her leg to Jack LaLanne. Jack LaLanne was a U. S. exercise guru who was a chiropractor. He ended up going into the world of exercise, becoming as a personal trainer he was a well-known exercise guru and he used to run a TV show.

That was one of the very first exercise TV shows back in the 60s. I would watch my mother do these exercises and then when I joined a gym at the age, of 22 my mother in her mid-40s also joined the gym, and she has been going to the gym ever since. She has been physically active throughout her entire life. You have those people that were that level, they are still doing things, they are still competing, and they are still blowing us away in marathons.

 

Their care has to focus on sprain or strain injuries. Now you get to weekend warriors, and those are the ones that want to go out and crush it because their college roommate just came into town and they are just going to go all in, because they used to play. They play for two hours and then they are coming into your practice limping. Their college roommate who flew in for the weekend didn’t tell his friend that they were playing tennis every day.

These weekend warriors just try to do it all in one day. We need to teach them how to temper it and add some movement during the week. Then you have the people that are realizing that they are declining in age. They have just retired from their job and now have time to exercise because that was their number one limitation while they were working. They want to get back into physical activity, but they cannot all afford a personal trainer.

With our care, we get them to start slowly, because they don’t have much muscle mass, they have a lot of disuse and we have to start to build a more reasonable pace. First of all, start with some motivation because exercise in aging, there are benefits to physical activity. Those benefits apply to the aging population, the same as they do to the high school kids, the college children, and the people that started in their careers.

My father was significantly overweight, when I graduated college, he looked at me and said, you better come up with some physical activity or you are going to be fat like me one day. He said, “Anne, you have played sports after school in high school and college teams ever since you were in sixth grade. You practice for 2 hours a day. The way you eat, if you don’t come up with some physical activity for the future, you are going to be fat.”

It did stimulate me and I joined a softball team, then I joined the gym when I was 22, and started teaching at the gym. Here I am at age 62, and I am still working out pretty much regularly every other day. Those are lifelong habits that we know will help us. People are starting to realize it, in all the papers that they are going to see declines in the loss of skeletal muscle strength and aerobic activity.

If they are going to lose that level of muscle, they are going to lose their mobility and their independence. Aerobic exercise is great for lowering blood pressure and that endurance training not only lowers blood pressure, but it will also alters the plasma lipoprotein profiles. You have a reduced risk of obesity. You can still eat a lot, still have the same rule that your output needs to be higher than your input. But you can control it a lot better if you are maintaining your physical activity.

Even if smokers and the obese start exercising in their later life, they are going to reduce their mortality rates. That is an important thing because a lot of times smokers don’t want to get that through their head and the obese is like, well there’s nothing I can do. Believe me, there’s always something you can do. These are some of the more important things I see because you want to prevent cardiovascular disorders. We know that movement is going to help that getting up those aerobics, even just walking on a treadmill if you cannot walk outside.

Diabetes, osteoporosis, and weight-bearing exercises are going to reduce your risks of that because women do have a much higher risk of osteoporosis and men can get it also. But we need more weight-bearing exercise not just sitting. Your colon cancer is moving around, you are going to get a lower probability of that. But what about mood disorders? Don’t we all build our endorphins when we exercise? But you have to get this through the head of your aging athlete.

The prevention of falls is huge because everybody thinks that balance training and core stability are the number one prevention of falls. Guess what? It is a toe push-off. You have to get strength in your toe. When you watch people walk, they start to walk with what I call that duck walk, their feet go out. If their toes are forward, they will grip when they fall forward. But if their feet are angled or one is angled and the others not there won’t be anything to grip them, and they have a higher probability of falling. I give the valley manoeuvre as an exercise to my patients for toe push-off to try to start to strengthen them so they can prevent themselves from falling.

Improve functional ability. Opportunities for social interaction, that is an interesting thing because you have people that are wanting to stay in their houses for longer periods, which means they are going to get isolated. It is not that they are just going to move to a nursing home, a group home, a senior living facility, or some of these over 55 neighbourhoods, which is a great place because they have activities in their clubhouses. But sports physical activity going to the gym, it is so nice when you go to the gym and they are like, “Where have you been for the past three days, we were here without you?” People care about this.

You have that social interaction, and that gives you that sense of well-being aside from endorphins, the fact that somebody loves you and wants to see you, like a work out partner. You may see improved sleep quality.

This is an important point. Physical activity is one of the very few interventions that can restore physiological capacity after it is lost, it is not a drug. Starting to move again and you can start to see those gains.

When you are evaluating these people, you have to look at the effects of aging and these must be considered during your diagnosis and treatment of the older adults.

On the slide in red, highlighted, “you don’t want a mistake pure aging for disease”. How many times has someone asked you a question and you say, “it is on the tip of my tongue” and I am saying, I am sure I will remember what I am thinking of at 2 AM, when all of a sudden I wake up. That is slow information retrieval, that’s not dementia.

We build up so many things in our brains and we cannot dump some things and it takes a little bit to run through all those files in our brain, that I just cannot dump. Even though I am using a Mac 11 computer, I have different files and have to find what I am looking for. That is exactly what I am talking about. That is not dementia, that is just overloading. Don’t mistake pure aging for disease, or disease for pure aging.

My dad had something called NPH, Normal Pressure Hydrocephalus, it was a water build-up on the brain. He was having some trouble walking. He had diabetes and he had some trouble with incontinence having had prostate cancer. His mother had Alzheimer’s. He went to the neurologist and the neurologist was, this is not aging, it is NPH and they had to drop a shunt in the brain to drain the water. He was clear as a whistle and he could walk again, all the problems started to clear out.

Keep in mind, if there is something that is just not right, start talking to other people in the family, and then maybe you can get a solid diagnosis. By the way, I am no expertise on NPH. It was not until my dad went to the neurologist and got everything checked that the mystery was solved.

Do not ignore the increased risk of adverse drug effects on weekly link systems. When you have a system that is overly stressed by illness, those drug effects can be very debilitating. When drugs were created, they would test on a 150-pound man. 60 kg is 134 pounds. I am going to say 72, 74 kg, that is where they were tested. They were not being tested on the 110 lb, 70-year-old woman. The 52 kg were not being tested on someone that was 80 kg, they were tested on a certain window. As a result, the drugs would have different effects, and those drug effects could be pretty debilitating.

Let us not forget the older adults that have multiple underlying disorders. Ian McClain, who was a radiologist in my Chiropractic College was very clear to say this, “A patient is entitled to have more than one thing wrong with them.” Unfortunately, as we age, that is going to be very true. More often than not, you are going to see a lot of things mixing together. You are going to see the comorbidities tip. You are going to see things that can be very life-threatening mixed up together.

You have to pay attention to all of that and a referral is warranted. Some of the problems are associated with aging but not necessarily because we do see people now in the younger ages with obesity which then promotes cardiovascular disease. They are going to have respiratory changes because of carrying an extra load. They are coming up the stairs and their oxygen is going to be maybe a little lower because you are not going to have the elasticity in the bronchioles that they had when they were younger.

You are going to see a neurological decline. You are going to see neuropsychiatric changes. They are going to get a little irritable. Why are they getting irritable? Maybe they cannot see as well. Maybe they cannot move as quickly, and it gets irritating. There are going to be gastrointestinal and genitourinary changes. They may be only able to eat a little less. One of the things that I was very excited about in the ARP magazine, the one that they start sending to you when you are 50 is they talked about how the protein needs are much higher as we age. That is because we have got less muscle mass and we need to build more muscle and that’s what the protein is going to do.

You have a lot of them carving out there wondering why they cannot lose weight when they have not been eating that much, but it is the quality and sure enough, I popped my protein back up to 28 grams per meal. The weight is starting to come back off because I am pushing it with the lifting. You need the protein to build that muscle and you are going to see the musculoskeletal changes.

My son is 31 years old. He is an ER physician, he looked at me one day and he said, “Mom, you are in great shape but let us face reality, your muscles and ligaments are still 60.” When I looked at the stats, at age 25, it takes a force of about 250 pounds to tear your knee; ACL, meniscus.

When you are 60, it takes the force of 125 pounds, it is half the force when you are older, because the elastin is not there, and the cartilage is a little bit thinner. Those are all considerations. Then, we have our special circumstances recovering from a stroke, cancer, and osteoporosis. Don’t forget these people, they need to exercise. We need to keep them moving too and keep them at the best they can be.

Chronic disorders are probably going to need a complete medical examination before they start an activity. Some experts will recommend an exercise stress test for patients that have two or more cardiac risk factors. Hypertension and obesity are going to be the two most common. For those that plan on starting an activity, more strenuous than walking. Walking, as I said, is one of the top activities that people are going to do and it is usually where they start.

Older patients that are starting an exercise need to be screened to identify chronic disorders, so you can determine the appropriate activities. Because everybody can do something. It is no different than when we do our PPEs or Pre-participation Exams. Even if someone may have to be contraindicated, maybe to play basketball, maybe they can shoot, archery. There is always an activity we can find for somebody unless it is an unstable medical condition.

Anyone can begin brief periods of walking and then you want to increase that to 30 minutes five times a week. The screen is not necessary to have them start walking unless there are balance issues. We see this couple right here and they are using trekking poles. Trekking poles I know we are very popular overseas. They are just starting to make their way into the United States. People are using them more and more, but this is very common in Nordic walking. 

Norway, Sweden, and some of the upper Scandinavian countries have been doing it for a long time.  I took them out on the trail, and somebody giggled when they saw me. I said, “You give it a try.” All of a sudden, they say, “I am standing up a little straighter and I am moving faster.”  I went hiking with my son for my 60th birthday. We hiked a mountain called Old Rag and I brought the hiking poles out. My 29-year-old son said “Oh, don’t tell me, you are going to be one of those.”

I went, “I am bringing them with me. I don’t know where I am going to need them, but I am going to bring them”. We climbed up and I did not use them going uphill, but coming down scares me a little. We are coming down the mountain and I am ahead of my son, using the trekking poles to help stabilize me. I have to step down from a large boulder and I sudden hear sliding. I turn around and there is my 29-year-old son sitting on the trail, on a rock.

I said, “Can I help you?” He goes, “I am good”  I said, “Would you like a trekking pole?” He goes, “Maybe”. Then guess who used one of the poles for the whole way down while I used the other one. Make sure your patients are aware of this because it does move them along quickly. My mother used them as well, she was blown away by how much better she walked and how much better her core felt. That’s my spiel on trekking poles.

We are going to cover the PAR-Q. Now, it is called PAR-Q+. It was called the PAR-Q for many years and then they updated it. The PAR-Q+ is a seven-question health screen, for identifying pre-existing health conditions. It wants to cover the seven aspects of health, your aerobic, your anaerobic capacities, and your cardiorespiratory, so there are going to be some long questions and some hard questions.

Your strength, flexibility, neuromuscular function, and just your general performance. The thing that is unfortunate about the PAR-Q is it is only designed for ages 15 to 69, but that doesn’t mean if you are 72 or your patients are not 72 you shouldn’t still give it to them. It gives you a really good sense of what’s going on because you want to be able to say, “You know what, you might be 72 but you don’t have any risk factors. We are going to okay you to participate in this”. But it is entirely subjective.

They are going to be more honest than you can imagine, but it is going to identify some pre-existing conditions that might be marked a little bit by some consistent exercise. Let us take a look at the PAR-Q.

Aside from you seeing it in the slides, if you Google PAR-Q it is just going to come right up. This is the updated one obviously, from 2021. They do not update it every year. I think the last one was in 2011. We look at the seven questions and I am not going to read everything to you, just going to summarize. What we are going to start with is, has your doctor ever said that you have a heart condition or high blood pressure? Because sometimes they will say, “It is a little different than do you have it, it is more have you been told. But do you have pain in your chest at rest?” Because maybe they do, maybe they have not been to a doctor in a long time and mentioned anything like this. “Do you lose balance because of dizziness?”

That is a very strong possibility. They stand up and they are like, wait a minute, I am dizzy. I just sent a patient out for that recently because after working on him whether he’s working on his neck or whether I was working on his upper back or low back when he went to sit up, he was dizzy. I was like, “You know what? This is not normal”. I’ve known the man for eight years; I sent him out.

Other chronic medical conditions besides heart and blood pressure. What medication are you taking? Be aware of what the medications are. Be aware of the generic names. I like this one down here because it covers it. Have you had a bone, joint, soft tissue, muscle, ligament, or tendon problem? A lot of them will come in with tendonitis and we are seeing a lot of tendinitis from this great sport that’s taking the senior population by storm in the United States, which I will come to. 

Has your doctor ever said that you can only do a medically supervised activity? Because you know what? Maybe they were told that by their doctor, so they are coming to you for a different answer. Keep in mind, that patients can lie, we all know this. They don’t expect you to give them the questionnaire that maybe their doctor did. But if they are clear, then we have a green light full steam ahead and they can sign it off and you have it because you’ve now covered your butt, they get a copy, you get a copy.

If they answered yes, to anything, hey, guess what? We are rolling on to number two. Because even though we are not doing a full pre-participation exam on them, the screening questions are pretty darn good. Now, we also have the yellows, and the yellows are very simple because you know what? That doesn’t mean, no, it means, “We have to get this thing clear. You are running a fever, why don’t we wait a week to do this? You are running a cold, wait.”

One of the things that they could be running is bronchitis. In bronchitis, a lot of people will feel a little better when they are out doing some physical activity, and then they will be tanked later on at night. You got to get bronchitis too pretty well clear, but I feel so good when I am moving. But look at your two hours later, you are on the sofa trying to survive.

Back to PAR-Q. There are follow-up questions basically as what I am saying to those initial seven questions. The bottom line is that there are questions and athlete answers, yes. Just send them for a full evaluation, take it off your plate. I just wanted to go for a walk, it is becoming so complicated.

I am going to tell you about this picture, which came from the internet.  I hiked in Patagonia as my gift to myself for turning 60 and I did an 80 km hike. I went by myself, I met people. I walked into this one place, and we were in Argentina and this group comes in laughing and singing and there were about 15 of them. They were having the best time. It was a group from France. They were easily 10 to 15 years older than me. Yes, they did other trekking poles. They also all have their wine casks with them. They all brought wine from France, to be able to drink down in Argentina. I loved that group. They were just so exhilarating and what an inspiration, all of them were.

Back to the PAR-Q, these are your follow-up questions and again you can Google these. Do you have arthritis, osteoporosis, and a couple of questions for that? Do you have cancer? Because certain cancers are going to limit the types of activities they are going to do. Heart conditions, we have already hammered that so I am not going to keep going there. Blood pressure and metabolic, diabetes, what kind? These are a few more of the PAR-Q questions; respiratory disease and spinal cord injury. That’s going to put you into a different type of activity.

Watch the eating disorders. Because they can try to overdo and do themselves in, pay attention to that one. Strokes, and what about a medical condition that’s not listed? I will give you one, narcolepsy because I had a patient on the table and she fell asleep when the table was upright. I said “Excuse me.” The patient said, “I suppose, I should tell you, I have narcolepsy, you didn’t have it listed on your form.” Pay attention to that step. Back to the red, yellow, and green. Their signature, you keep a copy, they keep a copy.

What kind of exercise programs should we be looking at for the people that want to get back into these finesses? This woman is awesome, how much she’s lifting? Exercise programs are more strenuous than walking, they should have a combination of exercises. The four types are endurance, muscular strengthening, balance training, and flexibility.

 Tai Chi is more balance. Flexibility, you are thinking your yoga, and Pilates sometimes fall into their stretching programs. But the combination of exercises is really what is recommended. You are hoping to get a few of those mixed and they don’t need to do everything on the same day, they can mix it up. There’s no guideline on that or rule. This I put in here because I was so impressed. I got to tell you, this place where my mom had her knee replacement, was incredible. When we walked into the room, this sign right here, hourly exercises, it is in every room on this floor.

They were told to perform each exercise 10 times on each leg. Not just one leg, because we know about contralateral exercising on each leg every hour. First, they pump their ankles, their quad sets, and their heel slides, butt squeezes, single leg straight raised, and hip abduction. They were very clear in physical therapy with everybody and said, “Do not miss a day of doing these, if you do, you will have a miserable next day”. I was excited about that, because there were a couple of people who were saying, “Do I really have to do these every day.” and you say “Yes, you need to do them every day. You want to make this new leg work for you.”

The point I am making is you can always do something to start moving. Even if you are limited you can start with things like ankle pumps, heel slides, and butt squeezes. I love this down at the bottom, this is a rule to live by. Life has two rules. Number one, never quit. Number two, always remove remember, rule number one.

Let us look at the other things that they can do. We have seated exercises. They don’t need to sit on a ball, just throws a little bit of extra balance and core in there, some of them might need to sit a little wider than others but they could be sitting in a chair to start. They can use cuff waits for strength training on the ankle and the wrist. They can do some repeated movement with those because they may have that difficulty standing and walking.

Aquatics exercise programs are huge and work well for patients with arthritis. Usually, there is an instructor, and they now make these aerobics shoes. They cannot complain that their foot is hitting the bottom of the pool and it hurts. They make water aerobics shoes.

Patients should select the exercises they enjoy but they want to have all four included. Patients always ask me, what’s the best exercise? My answer is straightforward. It is the one that you will do. They say “I don’t love exercise.” I said, “Not today, you don’t, but you will.” Then, there are endurance exercises. The walking the cycling, they can get on a bike and pedal. They have the recumbent bikes; they can do that.  Some of them still like to dance, and they can do slow dancing. They can move around. They can just do side-to-side stepping its movement.

Remember that adage? What was it? Motion is lotion. There that will give you one back for the memory banks. Some like to swim and then you have your low-impact aerobic. Those are all some options. Here are your basic guidelines, and this comes to us from the National Academy of Sports Medicine and the Aerobic Fitness Associations.

Aquatics, chair-based resistance, cycle, basic or beginner yoga. Three to five days a week, start at moderate, three days vigorous. You don’t want to ever have two intense days back-to-back, that will crush him. You can have some moderate days. You can have some light days and you can have some vigorous days. Those are your ideas. You want 30 to 60 minutes a day, but they can do them in 8 to 10-minute bouts. I love Peloton because they’ll do a 10-minute class.

Then maybe the next hour I want to do another 10 minutes and then maybe the next there’s no rule that they have to go somewhere and work 60 straight minutes or 30 straight minutes. If they are at their house, do something for 10 minutes. My son will get up on commercials and do 10 or 20 push-ups. Then the next couple of commercials, he might do 10 or 20 sit-ups, and then the next one, he might do some squat jumps or some body weights so you can break it up for them and they’ll be able to think how to do this.

Your special considerations are that they need to progress slowly. We don’t want their first day to be their last. They want to progress maybe towards free sitting, freestanding, or getting up off the floor without using all the furniture in the room to get there. They want to breathe normally. I love what the top trainer said at my old gym Tyson’s Playground. “Exhale on the effort and remind them they need to breathe”. Breathe when it gets hard, that is where they exhale.

Slow, rhythmic, active, dynamic stretches. Some of them will use a self-myofascial release. Some of them will sit on a foam roller, and some of them will do some easy stretching. Some of them will have one of the Theragun or a hyper volt and want to use that to do some easy stretching. Just tell them to take it easy and respect their muscles and joints.

Look at this picture and the intensity in his eyes. He’s over 70, and has that racket, in an athletic stance, ready to go. That is what I want to see because you are going to see those people in your office and they are intense.

Let us talk about International trends. There are present and future trends for Senior Athletes’ Sports participation. These are the trends that we are going to be seeing in the next 5, 10, and 15 years. More seniors are going to be getting into exercise, and that is because they wish for long life and a healthier lifestyle. “Yes, maybe I won’t get to live longer with all I am doing, but I am going to make a great-looking corpse.” “I need to make sure that I continue moving”.

Health insurance companies are going to start to incentivize sports participation because that is going to reduce General Health Bill. Older women are increasingly becoming more active in sports, and there’s that need for social cohesion, which I covered earlier. There will be a generational impact. Right now, we are in the boomers that are all starting to cross into those elderly or senior ages. Gen X is next, and they are going to start aging to 60 years old. That generation was raised with sports and exercise and they will continue in sport because they already like their Sport and know it is important to stay healthy.

What are we going to see in products? There will be an increase in the number of products made specifically for the elderly, which they will start targeting that age group. The health insurance companies are going to stimulate Sports participation. Silver sneakers is a program that the YMCA ran for seniors.

You are going to see reductions in health insurance costs for people that are proving that they are going to the gym. Technology is going to play a bigger role because as we age, the modern senior citizen is becoming more and more tech-savvy and we are going to see eHealth and sports participation go hand in hand.

What do I mean by eHealth? Through Covid, they have been doing a lot of Telehealth and seniors are starting to get used to talking to the doctor on a computer. They are starting to do their videos and log into YouTube. They will be a lot of eHealth functions coming up in the future. We see wearables already in the younger generation but we are going to start to see them more in the older generation.

Sensors, we are moving towards clothes that have sensors. Voice technology, I will be sitting there and my phone will say what did you say? I wasn’t talking to you. That is what you are going to hear from “voice”, did you get up and move? The seniors will set it on their computer, have it on their watch that starts to buzz. You will see the seniors get involved in this type of technology and using their health and fitness parameters. 

Artificial intelligence will start to play a bigger role because not only are we going to be having the wearables, but they are going to tell you, your sodium is too low, you need to take electrolyte. The algorithms are going to start to build tailor-made programs for seniors.  The Sports and Fitness clubs will continue or increase to target senior citizens because a lot of people are not using the gym during the day and that’s downtime for them so they can use come up facilities and make a little increase in revenue because they will get more seniors coming in during the day when it is less crowded.

We are going to see senior playgrounds, and those are places specifically made for the older generation to play. In Cuba, I saw several playgrounds and a lot of different people using them. But the senior playgrounds will be catered to some slower or easier things for them to move around, perhaps an obstacle course where they can touch one thing to the next.

You are still going to see people playing golf, fitness, cycling, walking across the country, and doing yoga and Pilates. Those are all going to continue in popularity. But we are also going to see several sports teams. Several team sports become popular, and they are going to adjust to the specific age group. In Europe, they are playing walking football. That one interested me because they are not allowed to run. They are only allowed to jog I think for a couple of steps, but I didn’t read the rules to know them well, so you are going to have to check that out. There is one in Australia too. Most countries are starting to pull that out.

There are more Senior Games and Senior World Championships likely to be organized, and I will cover that in a minute. Then, of course, there are senior social platforms. One of my friends is in this group where they tell you when everyone’s going to meet at the court, you are going to start to see seniors getting that specific information going. Everybody needed such and such for a walk and there’s going to be more education related to health and sports for senior citizens with that healthy lifestyle.

Here we have walking football You can see they are walking as quickly as they can and there’s the ball down here. There’s the walking football team from Queensland. Now, this is the sport I was telling you about it is driving everyone nuts in America. They are all playing pickleball and it is a shorter court. They can fit a couple of them on a tennis court and they are going nuts and I am seeing a lot of tendonitis issues here because they are reaching.

Look at this lady right here, I think we are seeing tendinitis there too. Wait, I think we are seeing it on her arm too. They need scapular stabilization exercises people. What they are doing is they are just moving their elbow and they are not moving their whole shoulder. As a result, they are so killing their elbow. The first one, I had that came into me was literally in tears when I had to shut her down for three weeks to get everything else to build up. She used to work out all the time, but she got into this pickleball craze. The next thing, she’s playing pickleball for two hours, five days a week. She wonders why she’s getting tendonitis.

Be aware of that craze because if it is not in your country now, it is common. I Googled International Senior Sports competitions and I came up with the World Masters Games. It is an International Multi-Sport Event held every four years, and it was pretty large. Then I was so sad because it said anybody can participate over the age of 35. That means you are not going to see a lot of people in their 70s running into that one.

Some of the sports say you can go down to 25, I wanted to put a big X through there. Let us not play that one. Let us go and look at the next one. The Huntsman World Senior Games. That began in 1887, it was the World Senior Games and that was the same concept. The founders that came up with it, decided that the golden years were better when good health and physical fitness became a way of life, not just a random hobby. They decided to start a sporting event for men and women over age 55.

What ended up happening was people participated, but they decided they wanted to increase participation, so they drop the age down to 50 for the second year. This is still going. The Huntsman World Senior Games are played every year in St. George, Utah, they are an International Event. There are over 30 different sports, Japan to Russia has been there, Norway to Senegal. Athletes have come from all over the world and that is the truly largest annual multi-sport. It is annual, it is not every four years like the World Senior Games, it is annual.

Then I checked if there was an International Senior Olympics? Today, the meet is known as the Senior Games or Senior Olympics and they are now held in every state in the United States. It is not International. Perhaps an International Senior Games will be the next trend. If so, maybe that will be the next event for us to work through FICS.

[END]

English Direct Download PDF ICSC09 _Section 3_Pediatric Athlete

ICSC Culture Diversity Module 09
ICSC09 _Section 3_Pediatric Athlete
Instructor: Christine Foss
Video Lesson: 1:29:39

Welcome to The Pediatric Athlete. I would like to first go over how we consider the pediatric athlete a little bit differently than what we would what we would call “normal-age” athlete, which will be from late teens and through their 30s and 40s, and then our masters athlete, which we will also look at in another subsequent module. We need to think about how might we assess the pediatric athlete differently, what injuries are they more predisposed to or less predisposed to, and what do we need to be on the lookout for as sports chiropractors.

Our objectives for this lesson is to dive into the specific pediatric athlete and look a little bit deeper into how you might assess the different injury predispositions.

The first thing we think about is, age is a factor. It is a huge factor when we are considering injury, injury predisposition, and injury assessment. We think about some of the injuries that are only seen in certain age groups. That would be not unlike the masters athlete as well, but we will going to see a lot more of apophyseal injuries or growth plate injuries. We need to be familiar with those and be familiar with how to assess them and when to be suspicious that there is one present.

We also notice that some diseases are not sports injuries, although they may be present as such. For the youth athlete, sometimes they come with a health history and sometimes they do not come with a complete health history. Sometimes it is us that uncovers that health history. This is something that we need to keep our scope broad sometimes when we are evaluating the pediatric athlete, so we do not miss anything.

Age is a determining factor in overall prognosis. That is significant. When we think about the younger athlete, they tend to have a higher metabolic turnover. We tend to see healing happen at a more rapid rate than, the masters athlete, which is pretty interesting. Sometimes our medical math timeline on tissue healing is going to be a little bit different as far as return to sport considerations.

Think of the interesting statistic, the age of athletes and injury predisposition is your athlete’s performance, it is inversely proportional to age. The older the athlete, the lower the performance, typically. Then the younger the athlete, the higher level of performance. The athletic intensity and duration of activity will decrease with age. Their workout should look a little different. The load should look a little different. Their training should look a little different. Different injuries with different age groups are a huge consideration as we have already mentioned. We need to think about apophyseal injuries or Salter-Harris type fractures and all the Salter-Harris classifications.

You might have seen this graphic before in earlier modules. Youth sports is a huge culture in society today and thinking about where most of our injuries occur. Some parents are a little savvier and guide their children away from more of the higher impact sports in lieu of a less impact or less injury-prone sport, which is pretty smart for them to premeditate that. However, we need to consider which sports have the highest injury predisposition and then what injuries we see particularly with each sport. If we look at men’s football, this is American football here, it has an extremely high injury rate compared to women’s indoor track. Understanding where I might see most of my tendinopathies, it might be a lower limb tendinopathy in an indoor track. The higher predisposition for injury would be concussion in a football player like this. Very high predisposition there. 

As we look at sport teams in these youth athletes, we know that a large number of injuries in athletes occur are more musculoskeletal origin. Therefore, we need to own our soft tissue evaluation and our soft tissue skills, particularly for the youth athlete. We have both intrinsic and extrinsic factors as relating to sports injuries. Let us investigate a little bit more about what that means.

When we talk about extrinsic factor in injury predisposition, we think about the things like the level of competition, the skill level, the duration and intensity of the competition, the length of time that person’s been in sport, the weather. Things that that athlete cannot necessarily control, or they are controlled by outside sources — extraneous factors.

Intrinsic factors are things that are more inherently affect the youth athlete. It would be age, gender, and hormonal changes. Huge things with menstrual disturbances now and as the female athlete goes through her menstrual cycle, different changes in collagen formation, stability, injury predisposition. Super interesting stuff on the forefront of research today. Do they have a history of previous injury? The greatest predictor of injury is a history of previous injury. Therefore, these are intrinsic factors that are going to predispose a youth athlete for another injury.

Their levels of fitness. How are they coming into the sport? Are they physically able? Physically fit to do the sport, or is their fitness level low? Some children are born with hypotonia. With those low tone levels of muscle, their body has a different expectation of activity. We want to think about upper versus lower limb dominance.

As we have these youth athletes, think about how am I going to take a youth athlete and train their body well, so that we have a functioning quasi symmetrical healthy body as a young adult. That is a huge consideration as we are encouraging these youth athletes to participate in sports and physical activity. Posture and intrinsic factors such as poor technique, inadequate concentration, or metabolic things like not eating enough, not enough caloric intake for the activity you are doing — these intrinsic factors we tend to have a little bit more control over that we can manipulate and help our youth athletes perform at a higher level. 

We need to understand that these youth athletes do not have a lot of professional guidance sometimes. In many settings, they are just a parent that is coaching and then a parent that is caring for the athlete. When we see asymmetries or pain crop up, who is there to help these young athletes? That is where we come into play. I feel very strongly that us, as sports practitioners, need to be able to recognize when somebody needs a little assistance and be able to do really good quality musculoskeletal assessments in these youth athletes.

If we were to look at this young softball player, obviously, this young girl here, you can see the difference in her dominant. She is a pitcher. Right arm here versus left. That is something that is earned from lots of practice and lots of hard work — that muscular difference. However, how can I unwind that? What exercises can I teach this young athlete, so that she is not so dominant for the rest of her life. We need to have some of what I call unpeeling exercises or exercises that help us even them out from the repetitive motion stuff that they are doing. We are not going to change that, but I can give her exercise on the left side to balance her body out a little bit and help improve the overall performance of her kinetic chain, which is super important for trying to gain power out of the upper extremity.

For just thinking about the shoulder in and of itself, we always hear the term bursitis mentioned. However, if we think of the glenohumeral joint in the youth athlete with girls, the centers open. Not unlike any age athlete, or person that we are treating a shoulder, we need to think of it as a golf ball bouncing on a tee. We need to have the anterior structures and the posterior structures balancing that golf ball on the tee, as well as the superior and inferior structures. 

If we have somebody like the youth athlete that we just saw, that is really protracted in the end in the shoulder region so she is rolled forward quite a bit. We have a dominance of her anterior shoulder. Therefore, we have a weakness of posterior shoulder. If we have a weakness in our posterior shoulder, our eccentric contraction is poor for our external rotators. That means inefficiency in slowing down the arm as we throw. Then we are going to be prone to rotator cuff injury. We need to understand how the youth athlete, and at a very young age, try to balance their bodies a little bit more and make sure that that balance is lending itself to a healthy productive athletic life and a healthy productive adult life as well.

Common sports injuries of the elbow. We see a ton of lateral epicondylitis and tendinopathies, medial, what we call little leaguer’s elbow or medial epicondylitis in athletes. How is the youth athlete different? How does the structure of the elbow consider just a little bit different in the youth athlete than in somebody that is post-growth plate closure? When we think about elbow injuries here, we need to look at it in layers. I always usually like to start intraarticularly when I look at a joint and work extra-articularly. However, in this instance, this example lends itself to looking at the muscles first. If we think of just looking at a typical elbow regardless of age, we look at the lateral complex here, and we understand the difference between the extensors — the extensor carpi ulnaris, extensor digitorum, longus, extensor digitorum brevis.

We think about anconeus which you cannot see under here, but we think about this massive expanse of muscle that is trying its best to function with throwing or catching, or whether we are doing lacrosse or gymnastics landing and pushing off of the arms. If we understand a youth athlete, we need to understand that there is a growth plate issue. On top of these layers of muscle, we have six growth centers around the elbow. Some of them do not have solid points of origin or insertion because they are originating or inserting on a growth center and apophysis.

We have to understand the maturation of the athlete and this helps facilitate our accuracy of diagnosis because, really, that diagnosis is how we should be laser-focused. Getting a good diagnosis first before we decide what our treatment care plan should be. Reacquaint yourself with the elbow and the tri-joint complex, three joints here. That is the radial ulnar joint, the radial humeral joint, and of course, the ulnar humeral joint. All of those need to function in close proximity with a lot of muscles contracting and eccentrically and concentrically contracting in a small area. Once we increase the load too rapidly of a tendon that is when we start to see our tendinopathy injuries occur.

Let us just take a minute and look at the growth centers at the ages they appear. This is when they first appear. It appears in this order here. We use this order, CRITOE, and that is our mnemonic. C would be your capitulum and that would be here. This would be at age one. R is your radius. Here is your radial head. The interesting thing about this area is we are going to look at a couple different injuries of this area here from these two growth centers hitting up against each other. Two growth plates approximating each other — not optimal for injury prevention that is for sure. That is at age one and then age five to six. Also, at age five to six, we tend to see the medial epicondyle start forming there.

Remember there is a little bit of latitude with this, depending on the tender stage, the age of maturation of your athlete. Some high-level athletes, some elite athletes such as gymnasts tend to mature two years late. If we are talking about a five to six-year-old gymnast, we might be talking about a four-year-old gymnast, skeletal maturation-wise. Just keep that in mind.

Then we go ahead into our trochlea, which is at our six to nine-year-old age here. Then, we are going to go into your olecranon, really interesting insertion of our triceps there, so lots of triceps contraction around that eight to nine-year-olds. Then, our external or lateral epicondyle, 10 to 12 years old. This is really significant if we think about our little league pitchers or youth baseball players that are using that lateral epicondyle quite a bit to throw a baseball or softball. That is just forming at age 10 to 12. At that age, they are already quite active in sport. That means that that common extensor tendon is really floating in space and really pulling quite hard on this growth plate. Understanding these six growth centers for youth athletes are very important when we consider evaluating the elbow in an instance of elbow pain for the youth athlete.

Here is our CRITOE. Here is our age of origin. What we need to do is we need to use these ossification centers to assess skeletal age and injury predisposition. As we have somebody with elbow pain, we are going to evaluate their skeletal maturation age as we are doing our evaluation. That is important to consider and let us not neglect these growth centers. I bring the elbow up because it is a little more complex than most of the different regions of the upper and lower limb. Because of the throwing sport, or cradling sport, or landing and pushing off sports, this is one that we really should have sports chiropractor become quite familiar with.

What is interesting is although the growth centers of the elbow open in that CRITOE right from capitulum all the way down, they do not close in that order. They close in this random order here. Here is your mnemonic, from trochlea to capitulum, to lateral epicondyle, to medial, to olecranon, to radius. The radius was one of the first ones to form and it is one of the last ones to close, which makes it quite significant for radial head fractures in athletes. Females precede males in fusion of growth centers, and that is good to know. If you are looking at a female athlete, she will have that growth center close first before her male counterpart. Between 15 and 19 years old, most of the athletes will have complete fusion taking place.

Here is a great example of an elbow injury in a youth gymnast where we have the radial head here, and then here is the humerus. This is an MRI. Right here, well, let us look at the medial side here. We can see that that is a nice smooth contour. As we come over here, we are going to look at this area, the capitulum of the humerus. You can see it almost looks like someone took a bite out of it. This is called Panner’s disease. Panner’s disease is identical to an osteochondritis dissecans in someone with closed growth centers.

If you have an open growth center and you have a necrotic area of bone on your distal humerus in the capitulum area, this is from redundant stress of this radial head hitting up against this portion, this lateral portion of the humerus. Then it causes an area of necrosis. The bone dies, starts to flake off, and then pieces of bone float around in the joint and the athlete will tell you, “I feel like my hand cannot- my arm does not extend all the way or keeps getting stuck.” They have just a very vague type of pain. Once the growth plate is closed, we no longer call it Panner’s. We call it OCD, osteochondritis dissecans.

At that point, we have to understand that when we have an OCD lesion or Panner’s, we are going to use this term synonymously right now, there is a chance of re-injury for that, so we have it surgically corrected. Statistically, every two years they will have another necrotic episode. The intervention today is they go in and they clean this necrotic area out and they microfracture it by drilling little holes in this capitulum to perfuse it with blood and cause angiogenesis to occur. With this angiogenesis, it helps to revitalize that area of bone, and hopefully, re-profuse it with blood flow.

The interesting statistic on Panner’s disease and osteochondritis, particularly at the elbow, is that in 10% of the cases, that will be on the contralateral side. Typically, before doing a surgical intervention, we will image the other side as well just to see if they have an OCD lesion on the other side. Just a heads up on that, that will be something you will need to keep on top of.

 This is your osteochondritis. Here is just a regular bone in view, so that you can get a better idea if you are not super familiar with MRIs. Here is your radial head here. This is your capitulum. This is the trochlea portion of the humerus. This is from the humeral head just hitting up against that capitulum redundantly. We see this again. This is not an uncommon finding in youth sports, and they need to be removed from sport.

Some of them, if they are stable and you catch them early, can recover on their own. We want to think about modalities and treatment that brings blood flow to the area. If it becomes unstable and we have pieces of bone that have broken off, then it becomes a surgical fix where they have got to go in and have it surgically cleaned out and then microfracture. It will very much depend on the stage that you can catch this thing. If caught early enough, we might be able to reverse the process and get them to heal without surgery and just conservative care. 

We talked a little bit about the throwing athlete here. Here is a medial epicondylar fracture in a wrestler. That is just right here off the medial epicondyle. You can see this is an avulsion injury. The wrestler had his arm bent back in a wrestling match, and it just popped to that medial epicondyle off. He was still growing, although he was beginning to start to close his growth centers. This is not the best picture for us to look at the growth centers, but his other image can show that a little more clearly.

We have to understand the age. This needed to be surgically corrected because this was not necessarily healing and he had several fragments. They ended up having it pinned, and this is what the post-surgical films look like here. We had a very large pin put in just to bring that medial epicondyle back into approximation of the humerus, so it can heal more adequately. In this image here, we can see his growth center on his radius still open. Remember we said that was the last to close, so it is still open. He still got some growing to go. We want to make sure that we just keep an eye on him.

When we return him to sport, it should be very slow and strategic. When we have an injury such as this here, where we lose the medial epicondyle, let us think about the other structures in that area. The ulnar collateral ligament is one, too, that provides medial stability to the elbow. That is also going to be disrupted with this type of injury, so we are going to lose stability. As we work in athlete like this back, we need to understand we are looking for that stability and strength on the medial side of the elbow before we can safely return somebody like this to sport.

Here is the ulnar collateral ligament that we just mentioned. When we have a tear of this ulnar collateral ligament, it comes in three grades: grade 1, 2, or 3. That is just right off the medial epicondyle here. Can you imagine if we were to avulse this medial epicondyle off? I would have lost this insertion. I lose my medial stability of the elbows, then the elbow can easily bend laterally. This is a great one. We can heal a lot of these non-surgically if they are not completely ruptured because they scar down quite nicely. If we treat them well, we could do a little bit of soft tissue work and instrument-assisted soft tissue. We can stimulate collagen formation and help that heal and scar down a little bit. We can regrow, so to speak, the medial stability of the elbow.

Let us talk about elbow dislocation next. The elbow is not an uncommon joint to dislocate, nine and two tenths percent of elbow injuries are dislocations. We need to be very careful and diligent when we are evaluating elbows that we are not trying to adjust an elbow. Ninety-one and three tenths percent of elbow dislocations occur in boys, probably, because they are just a little more aggressive, more participation in contact sports. Contact is the most common mechanism of injury of course, not just a fall. Thirteen and six tenths percent of elbow dislocations require surgical intervention, which is a high number. This is some of the newer research that we have coming across an elbow dislocation. Please make sure, if you have an athlete, that you are checking to make sure we do not have a dislocation before we start manipulating or treating this elbow on the field. Checking for peripheral pulses, making sure we have good vasculature distally, and basically, we are going to splint them and get them off to the emergency department for imaging and then ortho consult for care.

The wrist comes into play with the youth athlete, this is your triangular fibrocartilage complex. This is the most common cause of wrist pain on the ulnar side. The function of that TFCC is to absorb the loads that transfer through the ulnar carpal joint. Think of that gymnast that is landing on their wrists repetitively. Let us say they have a little medial and lateral weakness. They are always ulnar deviating when they land. They are going to tear apart this TFCC complex because we need that stability on the ulnar side. Once we have a little bit of this happening because we had some muscular weakness or some inherent instability, we are going to really stress that out.

The anatomy of the TFCC is this articular disc, which is right underneath the distal ulnar here. We have this ulnar lunate ligament connecting the lunate to the ulna, and then your ulnar triquetral ligament connecting the triquetrum to the lunate. Your ulnar collateral ligament, and then your posterior radioulnar ligament, and then there is an anterior radioulnar ligament that you cannot see in this picture here. That is quite a complex that provides this radial stability.

You are going to be assessing your athlete by just having them make a fist in ulnar deviate, or you can passively ulnar deviate them. In doing that, you are compressing this complex. That, at most times, will reproduce the pain and we will know that we probably have a TFCC. We can brace. We can do some conservative care, but we need to reduce the ulnar deviated load to that area to try to get it to heal. There are quite several surgeries cultivating with the TFCC that we are seeing some good results and some not-so-good results. Let us exhaust conservative care before we move forward with any type of surgical intervention.

As we are working with youth athletes, you must understand your anatomy and the growth centers that are around the anatomy that is injured. If we are looking at the bony pelvis here, we need to remember the muscles that are significant for performance, and which muscles originate and insert around the hip. If we are just looking at this little picture here that I created, we need to… This is for your abdominals, we have an apophyseal area right here in your abdominals insert right on the iliac crest. Then your sartorius on your ASIS, your rec fem on your AIIS. Then you have your glute min and your glute med on that femoral head there.

This is your vastus lateralis, intermedius, and medialis on your femur, and then the psoas on the lesser trochanter, your hamstring and then your adductors along this pubic ramus area. What we do not see pictured here is rectus abdominis inserting right up here on the superior aspect of that pubic bone, which we see a lot for sports hernia. 

The incidence of pelvic avulsion fracture. Remember, we are going to see avulsion fractures in youth athletes. That is why, specifically, we are looking at this research. This is research done by Dragoni Rossi. This is acute avulsion fractures of the pelvis in the adolescent competitive athletes. It is super interesting that we found that the highest rate of pelvic avulsion fractures occur in gymnasts and soccer players.

Your ischial tuberosity is the number one most commonly avulsed bone in the body. Number one is ischial tuberosity. Then in subsequent order, your anterior inferior iliac spine, then your anterior superior iliac spine, your pubic symphysis, and then your iliac crest. That is the order of events that we see in these avulsion fractures. Appreciating and understanding how to evaluate for them is very important. A lot of it is done with a pelvic compression test, and then palpation of the area, followed by manual muscle test to see if we have lost strength to that muscle.

 Here is just a different pic, just a regular X-ray. I like to use the mnemonic A Sergeant in the Army, pictured in this slide on the left side. A is for abdominals, Sergeant is sartorius, rectus femoris, and then your glute complex, your med and min. If we are looking at the femur like clock, at that twelve, one o’clock position is your glute min, and then posterior to that is going to be where your glute med is. Then your iliopsoas is your lesser trochanter as we mentioned earlier. Number one, again, ischial tuberosity for your hamstring, and your adductors on your pubic symphysis.

We are going to palpate those structures on your athlete during your hip exams when they are supine. If they are a little uncomfortable with you palpating them in supine, put them in sideline position, and then you can more easily palpate this iliac crest, your ASIS and your AIIS. This rec fem, I found several rec fem avulsion fractures in athletes that were diagnosed as no injury at all. Just getting those palpating skills and then following up with your muscle test of these muscles will confirm your diagnosis for you.

As we talk about the youth athlete, let us talk for a minute about the difference between gender in a youth athlete. We know that injury rates among women are not different than men in general. However, there is a difference in the rate of injury for different body parts. Boys have a higher rate of injury due to their increased participation in higher risk sports. We tend to see the male youth athletes exhibit more injury and more severe injury than the female youth athlete. That is just basically they are participating in higher level of contact during sport, whereas the females are not so much.

We need to bring up ACL injuries in females and we need to appreciate that the youth athlete most commonly will occur in the female for an ACL injury. Why is that? We need to really understand and look more deeply into ACL injuries and gender predisposition for females because what we need to understand is how a female jumps and lands versus how a male jumps and lands.

A female will jump and land using her quadriceps. A male will jump and land using his hamstrings. If we think of just the origin insertion of this, your quadriceps attach on that tibial tubercle. Your ACL, the job of the ACL is to prevent anterior translation of the tibia and femur. This is your femur, and this is your tibia. The job of the ACL is to prevent this from happening. If I am landing with my quadriceps and my quadriceps are attaching on my tibial tubercle, it is contracting and pulling and shearing that ACL, so it is challenging it a little bit more.

Conversely, males jump and land with their hamstrings, and just by the sake of insertion, our hamstrings insert posteriorly on the tibia. As they jump and land, they are reducing the stress on the ACL by using their glutes and hamstrings. One thing we really can do for our female athletes is to teach them how to jump and land, and how to pivot off their foot with their weight on their heel a little bit more as opposed to their weight on their toe. These simple mechanics will help decrease the incidence of ACL tears and ruptures in females.

Also keeping in mind that 25% of all ACL surgical interventions that return to sport will re-rupture within the first year. I am going to say that again, 25% of all ACLs that are surgically repaired will re-rupture on the surgical side or on the contralateral side of surgery within one year of return to sport. We really look through the research to figure out why do we see this predisposition. Mostly, it is because we have not adequately taught them the change in biomechanics in their physical therapy regime. We need to get them doing jump and land training just as part of their injury return to sport. That should be just as important as the muscle building that is happening in our ACL recovery. 

Here is some of these statistics that reiterate that fact, just done in 2021 by the way. This is a staggering number of athletes that must have a second surgical intervention. I mean, most athletes, after they re-rupture do not return to sport. That is another nine months of rehab and another surgery. We really need to make sure we do a better job in looking at the mechanics of somebody that returns to sport and that they are not jumping and landing and pivoting off their foot inadequately.

Continuing on looking at males versus females, we are going to look at some more stats and injury predisposition. If we just think of males versus females, we look at stroke volume and we know that women have a decreased stroke volume than men. Therefore, their overall cardiovascular endurance is decreased compared to their male counterparts. This is true for the pediatric athlete as well. Women have a 30% decrease cardiac output. Women have a higher respiration rate, so higher fatigability. Less total lung capacity than men.

However, even though these things are there, women have a difference in their fatigue resistance. Even though they are set up on that oxygen consumption scale a little bit different in increasing lactic acid production, they tend to have a greater resistance to fatigue. They just can combat fatigue a little bit better. Interesting that women can outperform men in cold water endurance challenges. Who knew? How do we figure that out? We know that we can acclimatize a little bit differently as females, but this is not unlike the pediatric female versus pediatric male athlete. We are going to see the same statistics.

The interesting thing with looking at cardiac differences in adolescent athletes, we need to understand if we compare the adolescent athlete to the adult athlete, with the adolescent athlete training, resting heart rate is going to decrease. When we compare that to the adult, the resting heart rate is still higher than the adult. They still have higher beats per minute than the adult counterpart. The interesting thing, too, with a trained youth athlete and adolescent athlete, we have dilation that occurs at that left atrium. Now, with comparison to an adult, we have a similar response that occurs. The left ventricle of the youth athlete dilates with mild left ventricular hypertrophy occurring. The thing about the adult athlete, we do not get that chamber dilation, but we get the hypertrophy. For the adult, that tells us the muscles working hard, but we do not have the dilation of the chamber.

We would think for the adult athlete, we are increasing the VO2 max or the ejection fraction, whereas the ejection fraction is not as robust in the adolescent athlete of equal training. For the adolescent athlete, cardiovascularly, we do see an increase in VO2 max. When we compared to the adult athlete, they have a lower VO2 max in comparison to their body size. If we look at the youth athlete, compared to their body size, they are not producing the VO2 max that their adult counterparts are producing. They have a lower stroke volume. We talked about that. That chamber dilation absorbs some of the resiliency of the ability for the heart to produce an injection fraction. 

Let us move on to looking at the femoral acetabular impingement syndrome or FAI for short. We look at this research study here published in 2021 on the incidence of femoral acetabular impingement and surgical management trends over time. We think about the 1,893 patients that were studied, and 813 were diagnosed with FAI. That is a big number. That is almost half. Females had a greater predisposition, 67% than males. The incidence of the FAI continues to increase annually. We know that we have a 600% increase in surgical interventions of femoral acetabular impingement and labral tears of the hip. We have to better understand how we can protect our youth athletes from going through an FAI-type syndrome as they mature. We think about FAI and we think about compression.

Let us look further into femoral acetabular impingement. If we think about the two different types, this is a cam deformity. There are three types of femoral acetabular impingement. The femoral neck out pocketing here is your cam femoral acetabular impingement. When we have a pincer, it is an overgrowth of the acetabular ridge here. Most commonly, I think it is about 87%, we have a mixed. The acetabular ridge is hitting up against the cam. Chicken or the egg, who knows which came first, but they both react and they both continue to grow.

Wolff’s Law, reaction along the- bone is going to lay down along the vectors of force. That is what happens here and then we continue to proliferate on both the acetabular ridge and the neck of the femur. This mostly occurs with flexion, kicking activities, and change of direction type sports. We think of the youth athlete and how is this significant? We need to get control of femoral acetabular impingement and we need to get control of labral tears in the hip. We are seeing such a dramatic increase in our youth athletes with hip injuries, hip pathologies.

This surgically can get fixed, but the hip is never really the same. We must take a moment and think about how is that anterior hip more predisposed. A lot of that is femoral neck angle or inadequate training and strengthening of the anterior hip capsule, and anterior structures as well, and as well as glute med weakness. We need to take these youth athletes and train them a little bit better instead of just making them run for three different sports, maybe three games a day in soccer. We need to go back and focus on some rehabilitation of the hip to prevent these injuries.

Let us talk about our pre-participation physical examination in club sports. We are going to call that PPE, and that is for pre-participation examination. That means that is an examination that we are going to do before the season starts. Some of these youth athletes do not necessarily have a sports exam before commencing their season. Typically, as the athlete gets a little older and they go into secondary school or college, they tend to have a requirement of having these physical exams. However, that is not true for middle school and younger athletes. That is a growing population of athletes and a huge population of injured athletes. Some of these injuries can really be prevented if we just go ahead and we do a pre-participation physical exam.

I believe that is where us, as chiropractors, can really dominate and become an active role in these athletes’ careers in a positive way. If we can do an assessment, a functional movement assessment, assessment of strength, global strength, proprioception, agonistic and antagonistic muscle group comparisons in the preseason, then we can fix these things before there is an injury. It might be up to you to organize a preseason screening. That, significantly, will minimize the number of injuries during the season. That is the name of the game. Let us try to prevent as many injuries as possible.

If we were to consider trying to organize a pre-participation physical exam for a group or team near you, think about these components that need to be in there. Look for predisposing factors, so getting a good health history is important. Just a note about that, if the parent gives us the health history, we are going to have a 75% chance to have more accurate health history than if we have the health history from an adolescent. Having the parent fill out the health history information is quite vital to have a nice thorough record. We want to try to use this PPE to minimize injuries during this season. 

Some injuries are catastrophic. If we talk about acute cardiomyopathy, the first sign for some athletes is sudden death. Doing a PPE and including a cardiac screening would be vital in preventing a catastrophic injury. The best practice to obtain and synthesize the athlete history is to formulate a clearance to participate. In other words, in order for the athlete to participate this year, we need to have a health clearance. You can work out with the coach or the team that you are working with.

Here are the components of our screening exam, what it should include. You should have a comprehensive personal and family history. That is the most important thing. Most of our injuries, as we said earlier, history of injury, the greatest predictor is history of previous injury.

We think about vital signs. We want a resting heart rate, blood pressure, that type of thing. A general inspection of skin and posture, an ears, eyes, nose and throat examination, cardiovascular and pulmonary screening, abdominal exam. It is very important that we have the conversation with children that have a single of paired organs, in other words, one kidney. We need to talk to them about contact sports and the participation or the lack of participation in a contact sport if you only have one of the paired organs.

A neurological exam is very important. If we have neurological issues, we might have delayed reaction time, which would predispose to many, many injuries. What is the genitourinary issue? If I need to examine this, I need to have a primary care doctor there. A full and complete musculoskeletal exam is important. This way really can see deficits. Do I have instability of the shoulder? Do I have instability of the knee? How can I prevent an injury by adding some exercises ahead of time?

The best time to do your pre-participation physical exam is about six to eight weeks before the season starts. This gives you enough time to do follow-up testing with doctors if they need it, and then also time to rehabilitate certain areas if they are having some weakness or instability. A good thing to do is get a bunch of doctors together. You can get a cardiologist, a primary care physician, and orthopedist, and yourself. You can, as a group, do a one day in the office and have each athlete see each one of you, and then we can formulate a nice pre-participation physical exam. Once your athlete passes all the components of the exam, then they are cleared to play.

That personal family history is very important. It is the most sensitive tool for us to help prevent injury. We want to make sure that we are getting to know if they have a bee sting allergy, if they have allergies to dogs or cats that maybe you would be on the field. What are other things that I need to be on the lookout if they are participating in sports that could be catastrophic if I did not know.

The cardiac exam we mentioned, it needs to include all the aspects of the American Heart Association guidelines, which includes listening to the heart. It is a core component to detect heart murmurs or abnormal heart sounds. All abnormalities should be evaluated by a cardiologist. If you have a primary care physician helping you with your PPE, if there are any abnormalities, they should see a cardiologist to get cleared.

Let us not forget about these psychological considerations of the youth athlete. You must understand, as a youth athlete, they do not really have control of their environment. The coach tells them what to do and how to do it. The parents tell them what to do and how to do it. We need to be on the lookout. As healthcare professionals, we forge a different relationship with the youth athlete. Sometimes they are going to look to you for guidance, or they might confide in you the feelings that they are having. The advice you give to an injured athlete is considered active care. Make sure that you are responsible in referring to the proper person, and then also guiding them appropriately.

This also can be deemed the patient involvement phase. We can have the patient do some active care and really try to work on the psychological component. I like to call a referral in this venue a mental strength coach instead of saying, “I would like to send you to a sports psychologist.” Sometimes some people have a negative connotation to that. If we could use that trend and use the term mental strength coach, that resonates a little easier with these young athletes that do not want to feel as though something is wrong with them. They could use, sometimes, somebody to talk to. They could use some tools in managing coaching pressures or parent pressures, stress of performance. It is a good idea to be on the lookout at this as healthcare professionals. We need to be ready and have some good professionals that you can refer to.

The Psychosocial Implications of Sports Specialization in Pediatric Athletes — this is a super interesting article that was just put out for us to go through. This is the journal about the training in 2019. This specialization in sport, in other words, these athletes that are doing one sport year-round, it requires increased training hours. The athletes have some social isolation that happens. They have a decrease or decline in academic performance. They have an increase in anxiety, greater stress, less sleep, decreased family time, and hence, burnout.

We really need to appreciate that these youth and pediatric athletes need some guidance. We need to have a better hold on the pressures that we are putting on them as a society, but also parents and coaches. They need to be age-appropriate stresses. I think that makes it very difficult for us to adequately look at the signs and symptoms of these youth athletes and making sure we are looking for signs of burnout. They can sometimes be hard to detect. It is important to be able to diagnose this. They are going to display vague symptoms of fatigue, or they are not going to recover. They started having injuries that are cropping up, and they just do not seem as motivated to return to sport. Be on the lookout for this. This is a big red flag for psychological issues or psychosocial issues that are coming down the pike. We want to try to catch them before they fall, so to speak. 

Concussion is a super-hot topic. We are waiting for the new Berlin concussion consensus to come out, particularly for the youth athlete. Why is it different for the youth athlete? It is because not only do they need to return to sport, but they also need to return to school and learning. We do have some stressors that are placed on them for test taking and sitting in class that maybe is not there for an athlete that is not of school age. As we are anxiously waiting for the new Berlin statement to come out — COVID has delayed it a little bit — we need to really understand and appreciate how we are evaluating the youth athlete for head injury.

A little more detailed history as two previous concussions is important. We are not going to leave any athlete unsupervised that has had a head injury. We are going to sit on the sidelines with them, and re-evaluate them every five minutes. I know we went through this in your head injury module, but it is worth reiterating. Performing those serial neuro assessments is very important. Determine the disposition of symptoms even if they are asymptomatic. We want to make sure that we have a post-injury follow-up, a return to play plan, home observation, and a hospital transport if needed.

Provide post-event instructions. Making sure we speak to a mother, a guardian, or a father, and making sure that we are giving good instruction as to if the head injury gets worse. What do we need to do? Do we need to go to the hospital? Do we need to follow up with your primary care doctor? How do we return this athlete to sports safely? As we are dealing with the adolescent athlete, we also need to understand that we got to deal with guardians or parents. Somebody is caring for the athlete. How are we getting the athlete home? Who is going to schedule the appointment to follow up with the athlete? Can the athlete get a ride back to see us? Some different dynamics as we are dealing with the pediatric athlete that we really need to consider. 

Return to play. This is a return to sport strategy off of the Berlin consensus statement. We talked about this quite a bit in the head injury module. How do we want to gradually and strategically increase blood pressure and heart rate to challenge the athlete to see if they have a return of symptoms. If they have a return of symptoms, the testing is done for the day. They go home, and then come back the next day and retry again from that level.

That is the stages here on the left side. If they are symptomatic, in daily activities, do not provoke symptoms. I can try to move them to level 2 where they can do some light aerobic exercise, like walking around the track. If that increases their symptoms, they are done for the day. They go home and rest. They can come back tomorrow, and we could try the light aerobic activity again. We start them again at stage 2. We do not progress until they can pass that stage. 

Where it is different for the adolescent is we have a return to school strategy, too, as part of the Berlin consensus statement. We need to understand how we guide them through these four stages in returning to school because we might have the athlete at stage one that cannot do homework or school work or should not really be reading. They need to do everything that just does not increase their symptoms.

As we go to stage two, we start to begin with school activities such as homework, reading, and other cognitive activities outside the classroom. We check to see that they have an increased tolerance to cognitive work.

Then stage three, as we start, we go back to school just part-time. As we go back to school part-time, we gradually introduce schoolwork and maybe we send them for half a day. We see how they respond. If they respond good, then we can graduate them and we can return them to sport more on a full-time basis. Then just really keeping an eye on how they are performing. If their symptoms are increasing, are they fatigued? Do they have headaches? Are they apathetic? In other words, they do not really have their normal emotions.

If we rush them back to school too soon, we noticed these symptoms take longer to get better. What we really need to do is strategically and slowly, not rush back to school activity. Return to school should precede the return to sport. We need to get back to school activity before we get them back to sport activity.

If we consider that structure is affected by function and function is affected by structure, we need to resonate with the fact that we are not all created equal and adolescents included in that, the pediatric athlete. They have growth centers that are open. Their arches are forming at different ages, muscularly. They are changing with the growing of bone itself. Muscle lags in growth, so they are intermittently getting tighter, and then looser, and then tighter, and then looser. We see lots of things that are happening differently because we have a different metabolic state in the youth athlete than the adult athlete. Things are changing all the time. We need to keep on top of this morphing of the body and work with these athletes. 

As we are rehabbing an athlete and bringing them back to sport, what we really need to consider is adding sports-specific drills to the pediatric athlete as part of your recovery strategy as soon as possible in your recovery care plan. What we want to do is we want to build on foundational movements of what your athlete needs to accomplish. What type of sport are they in? How many hours a week do they need to perform? What specialty do they have in a sport?

If they are gymnast, these are a bunch of little gymnast here, are they balance beam? Are they vaulters? Are they floor? Therefore, they are going to use their muscles differently. Then also as a whole, what is their level of fitness? Do I need to work on their kinematic chain to get them a little more injury-proof, more built of Teflon, so to speak, to prevent injury later on? Maybe somewhere else in the kinetic chain. We need to cross-train them and get an idea of where the deficits other than the injury, so that I can help progress them a little bit quicker.

Look at the footwear. These youth athletes, mothers and fathers, most of the times, invest a lot of money in shoes because they are ever growing and changing. They would be buying expensive shoes very frequently. That puts our youth athletes at a very high risk for injury, but also a lower performance. Shoes are very important. Adequate footwear is very important for performance, but also injury predisposition. Get the shoes that they commonly practice in for the youth athlete. I want to see what the quality is of the shoe? What is the parent buying this athlete? Is this just an off-the-shelf Target type of shoe, or we have a nice running shoe from a running store? Let us look at the wear patterns.

Not unlike the adult but understand where patterns might change as an athlete grows. Shoes might get tighter, and they might change their gait pattern. We need to appreciate and be ready to evaluate that, and that is a little different than the adult athlete.

Ask the youth athlete about taping or braces. Did a coach tell them to wear a brace? What about past injuries? Again, we cannot reiterate that enough. Then we are going to ask them about foot or ankle pain, hip, or low back pain. The pediatric athlete is not the best communicator, typically, and they are not good historians. We need to be ready to ask the questions because they are not going to necessarily offer the answers that we are looking for that would help us better treat them. Making sure that we are a little more inquisitive with the youth athlete and a little more communicative on our part as healthcare providers, so that we can extrapolate the best information from the athletes that we can better treat them.

Pull your picture together, and I always say, retest your theory and retest your theory because pediatric athletes are ever-changing in height, weight, size, and performance, and how many hours a week they are practicing or not. We need to keep on top of them. They need to be a regular patient, so that we can prevent injury.

Looking at that shoe wear pattern, making sure they are tying their shoes. This makes me crazy when someone does not tie their shoe. These are the shoes of somebody who is a youth athlete who wore them for four years straight and never changed his shoes. From the shoes he wore to school, to the shoes he wore to football practice, to the shoes he wore to church, same shoes. We need to understand and appreciate that. Sometimes we are going to have to educate the parents as to what an athlete needs. Just because they are young, it does not mean their needs are different than a more mature athlete.

Making sure we are looking at the inspection. We are inspecting the shoe from all angles. I like to look at the back of the shoe, the top of the shoe. I like to look at the bottom of the shoe, like we just looked at in the last slide.

Making sure we have them putting on the shoes they wear for practice and doing functional movements. I like to get my athletes on the treadmill walking or on the ground if they are not used to a treadmill. I want to see how they squat, bend, jump, land. We want to see them in the shoes that they wear for practice now. If they are in a sport that is not a footwear sport like dance or gymnastics, then we want to see them doing these tasks without shoes on. That is important.

When does the return to sport plan begin, as your youth athlete? How is that different than the adult athlete? What is your measure of readiness? How are you going to progress and return the athlete to play? Also, what is your timeline, the level of play, and the measure of injury would demand at sport for that region? What we need to really understand is as we are getting somebody to return to sport, that youth athlete, what position are they going into? What is the terrain they are running on? Are they running on a track? Are they running on grass or turf? What type of footwear are they going to be wearing? Let us start our whole return to play plan as early as possible and start instituting a kinetic chain strengthening exercises, so that we can prepare them for their return.

What we have to get away from is over-immobilizing or over-resting the area instead of training the other areas to get stronger around it. I guess the best explanation is we can have a runner who cannot run maybe jogging in the water with a vest on so they can float. For a runner who cannot run due to stress related injury in the foot, maybe we can work on hip flexor strengthening, maybe we can work on balance on the other leg, maybe we can work on lumbar extension strengthening exercises, stability exercises. Thinking about other ways to keep them cross-trained is important, so as they return, they have a smoother transition back into sport with strength as opposed to now they have got to start with an amount of global atrophy through their body. We want to prevent that.

Let us know what is normal for your patient. As you are looking at athletes, you need to understand what is their range of motion, and what do they need for their sport? What does this athlete need from his hip in order to do his activity? What range of motion would be normal? Most importantly, as I am considering the care plan, what type of muscle fiber does this athlete need? Is it a gymnast? That is a fast-twitch muscle fiber type of athlete. Is it an endurance runner, or distance runner that is a slow-twitch? My care plan needs to facilitate the type of muscle fiber recovery as well. We do not want to be out-training from sport by taking our fast-twitch fibers and making them slow-twitch by having are bursting gymnasts do a long-term endurance activities in the recovery phase. That is an important consideration. 

Let us take the time for all our injured pediatric athletes to teach them how to stretch well. That is a life lesson that will carry them through a healthier body all the way through their athletic career. Take the time to teach them the difference between dynamic and static stretching and when they might want to do them. When is the right time to stretch? We want to teach that pediatric athlete how they want to stretch when their bodies a little bit warm versus when it is cold? How long did they need to hold each stretch? We need to get each pediatric athlete that you are treating more educated, so that then, they stay healthier and healthier over the years.

Also understanding that we have different phases of care. What is appropriate as you are treating the pediatric athlete and how that might be different than the young adult athlete or the masters athlete. Some of these might be different, but again, these phases of care for the pediatric athlete, they might move through these phases of care a little quicker because they have a higher metabolic turnover. Just be on the lookout. They might get better a little faster than everybody else.

Still in that acute phase for the pediatric athlete, we are still going to do our rest, ice, compression, and elevation. I know there is a lot of discussion on ice. I have moved away from ice quite a bit. Most of my injuries, however, in the first 24-48 hours, I still do ice. If there is still a good amount of swelling at that point, I will go one more day to 72 hours and then I am over to heat. By day 3, I am not using ice anymore unless there is a lot of reactive edema at the end of each day.

Your mission in this acute phase is to decrease edema. That is what your mission needs to be. Take your youth athlete and let us educate them on why that edema is so critical to get rid of, how they are going to do that, and why they need to take control. We are teaching our youth athletes to take control of their body and learn how to manipulate their body in their favor. This way, we are going to run into healthier adult athletes and understand the safety in different types of braces. Make sure they are not wearing their brother’s or sister’s brace that does something different than the injury that they have. If they are using crutches, we are educating them on how to use the crutches appropriately.

Understanding the progressions. As we are teaching these youth athletes stretches, how are we going to progress them? They are going to be moving quite quickly through your rehab. We want to stretch all four quadrants that, say, for stretching a hip. Let us teach them a bunch of different ways to stretch. It is really quite a nice advantage to take the youth athlete and educate them because they become superior athletes.

In your subacute phase, we are going to start working on muscle synergy, contraction, and proprioception. We are going to always continue with edema reduction. We are going to continue and we are going to be striving for range of motion. We begin our range of motion as soon as possible, most times by day two. After an injury, we have them start going through the range of motion in that body part. That is going to help facilitate decreased edema in the area as we are increasing range of motion.

We cannot progress them to sport-specific activities without full and restored range of motion. That is most important. Getting that edema out of there so that we can start with strengthening stuff is very important. Your subacute phase is continuing with the edema reduction and beginning muscle contraction. We are not doing tons of strengthening yet because we do not have full range of motion, but we are starting with some light-level range of motion type activities.

In our late subacute phase of care, we are moving into a full range of motion. We are beginning our strengthening. As we start getting range of motion, then I am starting to strengthen. You do not want to necessarily over-strengthen something that does not have a normal range of motion. Then we might be limiting attaining that normal range of motion.

For the youth athlete, we are going to take our time and walk them through with a little more detail, teaching them proprioception, stability, and safety, and progress them away from crutches or out of a sling if it is an upper limb problem. We want to understand this late acute phase is a big transition from simple, more passive care to more active care. By the end of the subacute phase, we want them in an active care model.

We need to start thinking about assessing the kinetic chain as your athlete starts to perform, as your athletes to improve through your phase of care. Now, the adolescent athlete, this is a great opportunity for us to pick up some kinetic chain weaknesses that we can fix and send them back to sport. Understand, your first step in assessing the kinetic chain is an accurate diagnosis first. You have got to get that accurate diagnosis, then we can assess functional.

We cannot really do a ton of functional movement assessments until they can walk, jump, or squat without a limp or without trying to dance around the pain that they have. If they have a primary complaint, that is an acute injury, we must first work through that a little bit. When we are ready, check the functional motion. However, conversely, if it is an athlete that comes with just a quirky something, that is not acute onset. It is more insidious in onset or gradual in onset. Then we are going to think about doing that functional movement the first day, and assessing squatting, posterior chain tightness, heel raises, and all types of gait analysis and whatnot. Our goal is to fix the primary complaint and fix the kinetic chain in the youth athlete because we are really protecting that youth athlete when we return them to sport then. 

Why do we worry so much about the kinetic chain and why is it such an important part of rehab is because we have a decreased joint load when we have an effective kinetic chain. When we have a dysfunction in the kinetic chain, we have increased stress on the distal segments. We are going to reduce injuries if we check that kinetic chain before we send them back to sport. If we send them back to sport half-broken, then they will come back to you broken again, the goal is injury prevention.

We think about this kinetic chain and how I might look at it. If we are just looking at this region here, I want you to look at just the first row and let us just look at the sagittal plane. I want you to ignore the last two rows, this frontal plane and transverse plane. Let us ignore these two rows. Let us look at the effects of pronation and let us call it hyper pronation. If we think about just pronation which needs to occur in a normal gait, we have to think in the low back. Your back goes into extension with normal pronation. Your pelvis has to rock anteriorly. Your mid tarsal joints all need to dorsiflex.

If we think about the frontal plane, you have to laterally flex the same side and the transverse plane, your low back, has to protract. The pelvis has to translate and has ipsilateral elevation. On the transverse plane, your pelvis must rotate forward. All the mid tarsal joints must go through abduction and all the mid tarsal joints have to go through inversion in the frontal plane.

Lots of things need to happen with pronation, however, with hyper pronation, this happens in excess, this cascade of events. We think about inserts and whatnot for the youth athlete. It is important. Some of the insides of these turf shoes are just an empty shell. We need to offer our athletes a little more assistance, so an off-the-shelf type of orthotic is not a bad idea at all. That might significantly help us prevent a bunch of injuries by improving the gait cycle and increasing the power generated through the kinetic chain.

Because what we need to understand is the functional anatomy. Not only are we looking at the intra-articular structures, the ligaments, tendons, muscles, and fascia as we work from inside out, but we are also looking for the athlete in a different way. How the bone might grow, lengthen, and what happens to the muscles in that way? We need to really be thinking about the layers of anatomy, but how is this different in the pediatric athlete? How is the bony structure different? We talked about apophyseal injuries. How is the connective tissue different? We talked that the bony insertion, the bony attachment is weaker than the connective tissue. Therefore we have apophyseal injuries because the bone comes off because the tendons are a little bit stronger than the bone.

We need to talk about how the muscular compensatory layers are a little bit different in the youth athlete than the adult. Same thing with intermediate and superficial layers, and then fascia, too. For that pediatric athlete, they are not different in many instances than the adult athlete fascially, but we need to keep them healthy. We cannot just assume they can play three different games of soccer in one day. We need to understand they need to recover as well. Their bodies need to recover.

Looking at gait of the pediatric athlete is important because sometimes we can truly appreciate where we have breaks in the kinetic chain. We can learn to fix these early and prevent a whole bunch of injuries. If we look at this athlete here, just in this step position here, you can see her left foot is quite turned in. She actually has an over-facilitated posterior tibialis tendon and an inhibited fibularis complex here. This stress in this type of a gait left unfixed for this youth athlete will cause anterior head compartment to eccentrically contract and increase the load on that anterior hip a little bit more.

As your heel hits down and you start to swing through, this is the phase that we have a lot of anterior hip forces. What we need to think about is getting that gait to improve in these youth athletes. Correcting these gait abnormalities is critical to prevent a whole host of injuries that happen intraarticularly and extra-articularly.

If we think about gait and we move on to the knee, we think about knee flexion creates a smooth transition with the contact to the foot. We need to have normal range of motion of each region, of each joint from the lumbar spine down to have normal gait. If we have an abnormality like in this picture here, where I have already started my gait pattern faulty, then I am having faulty stresses placed on the knee, the hip, and the lumbar spine as well. We need to think about that correction myopically will fix the whole kinetic chain.

This is my most beautiful artistic rendition of muscle contraction that occurs during the stance and swing phase of gait. For the youth athlete, we need to appreciate how are we getting our strength as we go through the gait cycle. We think about training these young athletes. We need to make sure we have strength training that can occur, so that they can adequately facilitate the use of these muscles.

Let us just think about hip adductors here. Look at how long along the gait cycle right here that this needs to contract. That needs to be an endurance-trained muscle. Appreciating the gait cycle between the stance phase, the phase your foot is on the ground or made contact to the ground, versus the swing phase, which is the green at the top up here. When your leg is swinging through your gait, we can see that we need a lot less robust use of the muscles, the large muscle groups around the hip region, and knee region than we do when we put our heel down and start propelling ourselves forward. That particular use of these muscle groups is important to appreciate, and also, so we can adequately trained our youth athletes. If we are running, then we need to generate this force in a shorter period of time. We need to train our athletes, our youth athletes, appropriately.

When is it appropriate to start strength training in children? There is a lot of debate about this in our pediatric athlete. If we scroll on any of the social media applications, we can see some of these young kids squatting and lifting weights and whatnot. I do not know how everybody feels about that. Back in the day, they used to purport that it closes the growth center prematurely. I have read research on both sides of the fence on this one. I like to say it is better to start your strength training and your rehab as possible. Let us just be smart about it. Let us just make sure we are tuning into the athlete and what they really need, what their body needs, and let us slowly and strategically increase the load and force in which we are demanding that strength from them.

What are your limiting factors? Are they limited by range of motion? Are they limited by intensity? What are they limited by? For the pediatric athlete, different considerations as we start instituting a strength training program. When is it appropriate to progress? We need to have that strategic stepwise progression where we are gradually increasing loaded intensity as they are able to complete a task. If we can walk without a limp, that means we can do walking activities. If we can run without a limp, that means they can do running activities. If they can do strength training with full range of motion without pain and inflammation, then they can add in their strength training. I typically like to give an exercise and see how they fare with it over 24 hours. When they come back, if they are not sore, worse, or inflamed, then I add more. I strategically like to keep adding that way. 

We talked a little bit about introducing sport-specific drills and how important it is for us to introduce these sports-specific drills early on in your training program, but we need to build on foundational movements with the sport. Also, we need to work on timing, athlete reaction, and anticipation. We also need to cross-train them to gain control of other body parts. We cannot always myopically just train somebody for one sport. We are globally missing the boat if that is the case. We need to have our pediatric athletes cross-trained. If we look at this graphic on the right bottom from Jill Cook out of London on her research on tendon load and tendon reintroduction, graduated returning to running program.

With the tendon injury, we always are going to start here with our isometric work first. A real tendon condition is a condition of necrosis to the tendon. This tendonitis type term is an older term. What we want to think about is that with a chronic tendon issue, the tendon is in a necrotic state that blocks the blood flow to be healthy. We need to introduce angiogenesis or blood flow slowly and strategically to the area during our rehabilitation phase.

We are going to start with isometric work, then we are going to go into strengthening, and then more functional strengthening, then speed. We are not going to add speed till later. Plyometrics are going to be added last. It is very important that we pay attention to the stepwise progression. We are going to gradually increase intensity, volume, and frequency over time. This gives the tendon a chance to hypertrophy. Just like we are waiting for the muscle hypertrophy. If we overload the tendon too soon, we will have a re-injury for sure.

If we can look at this picture here of these athletes running, I like to point this out because we talked about the kinetic chain and what I might want to work on. I am always looking at movement, how everybody is moving, and how their bodies are performing. If we can look at this athlete here running and see how she has that what we call triple extension in running, hip extended, knee extended, and your foot extended. That triple extension is important for good forward propulsion.

We can we see this athlete here is lacking a lot of triple extension and she is more collapse on her body, more promoting lateral motion or slowing of her forward motion versus forward motion. No surprise that she is in last place of these athletes running here. We think about watching the movement of your pediatric athletes and seeing, retraining them for an injury care plan path. Let us retrain them so that we can send them back to sport and improve more injury-resilient athlete. 

We talked about pronation and hyper pronation. In the youth athlete, again, that footwear is critical. Making sure that we decide if we need an orthotic, or an insert is appropriate. As we get them in an insert, let us take that pediatric athlete back to the office with their shoes and their insert and let us watch them walk in it. It is very important that we establish a patellar neutral position. We also allow a little bit of pronation. We see that excessive pronation is most common in running analysis, while most of these youth athletes are in running sports. Soccer, lacrosse, track and field, football — these running sports need to have adequate foot structure support as well, so a good shoe. If needed, if their arches have not formed adequately by age seven, then we need to maybe offer some support such as short foot exercises, put intrinsic muscle strengthening, spread your toes type of activities to help build that strength up. We are trying to take the youth athlete and make them healthy adult athletes.

With hyper pronation, we get an increased demand on muscles, which makes them work harder and that is along the whole kinetic chain. Just trying to fix this hyper pronation with doing your foot exercises, or if they need to use an orthotic while they are building their muscles or their intrinsic foot muscles back up. We need to think about we are preventing a lot of overuse and stress on the lower limb. With excessive pronation, it also promotes excessive internal rotation of the tibia and femur. This is a patellofemoral maltracking issue, which is the number one most common injury in all age groups, all people, athletes and non today. We need to look at the foot structure in the early stages.

As we are looking at our pediatric athlete’s gait, we need to understand that this is the controlled fall that occurs during gait analysis. What we need to really appreciate is that your foot needs to dorsiflex 10 degrees. We need to get it up at least 10 degrees. We need to get that great toe at least 30 to 50 degrees in extension. The tibia needs to internally rotate it. If you step down, your tibia is going to internally rotate. Your talus must evert and then your foot pronates. That is a controlled step. These things need to happen.

Also, with a pronation, we need to plantar flex. Extend and rotate, invert, and supinate. Now, we are dropping down in our gait here, and then we must do the opposite to recover. That is your bottom one. This is the step down here, and then this is the swing phase. We are going to talk about here. Accepting load in the top row, and then swinging through. What happens to your foot? Your foot is going to supinate. Your leg is going to abduct as you swing your leg through.

Always remember, for your pediatric athletes, make them part of your team. Give them homework to do. Make them part of active recovery. This is an unfair advantage that we have when we are treating pediatric athletes and youth athletes to teach them about their bodies, to teach them about how to care for themselves. This is a life lesson. Have them become an active part of the recovery, so that they can gain this knowledge and become better athletes, and again, more injury-proof as we go. I like to give all my athletes two homework exercises each time they come in. That is their homework so I see them back again, and then I will progress that. This keeps a nice active response in the recovery phase.

It is very important as we are working with pediatric athletes that we consider safe sport. Now, in the United States, we have something called the U.S. Center for SafeSport. Basically, this is training and education for the coach, the athlete, and the parents. For a very nominal fee, I think it is $24, you can get certified in Safe Sport. In the states here, to work with some level athletes, you need to be SafeSport-certified.

I strongly recommend it. It is a great education on what is the appropriate and not appropriate procedure when working with an athlete and when observing a coach working with an athlete.It is a great resource for parents to become acquainted with what should happen to athletes in practice, and what should not happen to athletes in practice. I encourage you to spend just a little bit of time getting SafeSport-certified. It does not take long at all. You can do it on the computer from home. You will really have an unbelievable knowledge of what the athlete goes through. Also, let us encourage some parents to get SafeSport-certified, so that they can know what to look out for. We can prevent a whole lot of youth injury predispositions or unfortunate circumstances if everybody was more educated. Everything begins with education.

As we are working with youth athletes, we need to make sure we take command of things such as helmet fitting. If you are working, whether you are working with American football, lacrosse, or any sport that is using any type of head gear or mouth gear, please know how to fit it appropriately, know the steps that are needed to make sure you have a fit, know how to inspect that equipment on the inside and out. Know when, for American football here, the bladder could be deflated. We had one athlete in town here who reported to his athletic trainer that his helmet did not seem to fit well and the athletic trainer said, “I checked them all. You are fine.” but did not take the time to check the athlete.

The athlete came in again the next day and said, “No, no, there is really a problem with my helmet. It does not feel right.” The athletic trainer, once again, said, “Your helmet is fine. Stop being neurotic. Go home.” The next day was a scrimmage. He had a traumatic brain injury. When they looked at his helmet, the bladder on the inside of the helmet was broken. The athletic trainer did not take the time to assess the equipment, even though he was asked two times by the athlete. Therefore, he has a very large lawsuit to the school system and the athletic trainer as well. Unfortunately, for this athletic trainer, the father of this athlete was a lawyer, so he did not bode well. Very unfortunate brain injury there, that is for sure.

Know how to inspect it, know what abnormal looks like, and know what normal looks like. It would not be bad to teach your athlete how to inspect their own, it all begins with education. When we are dealing with youth athletes, that education is a critical part of what we do.

When we talk about mouth guards, same rules apply. Know how to fit them and know how to know when your athlete has a good fit for a mouth guard versus a poor fit for a mouth guard. What we do know is that mouth guards can prevent a lot of oral facial injuries. It is an important component and a necessary required component, the uniform for many athletes. Please note, take a little time to read about mouth guards and understand a custom mouth guard versus a non-custom mouth guard and the advantages for your athlete. What about when these youth athletes have braces? How does a mouth guard fit differently? Do I need to get a different type of mouth guard when they have braces versus none? 

Here is a little bit of research on the effects of mouth guards on performance. What we notice is a neurophysiological feedback and mechanism. We have increased performance with mouth guards, which is actually pretty interesting. We do see repositioning of the mandible, and the patency of the nerves and arteries in the TMJ is improved, increased blood flow and perfusion of oxygen to the tissues, which may improve function.

One thing, I have some fun with it, have your athlete put their mouth guard and muscle test them. You will notice a big difference when you muscle test them when they are biting down on their mouth guard versus without a mouth guard in. They will be stronger. We notice this. Therefore, a lot of professional football teams take a good amount of time to make sure we really have a good fit for our football players for their mouth gear because we can exhibit greater arm strength with effective mouth gear. If we are talking about a lineman that is trying to push the line back, I could probably make sure he has a better mouth guard so he can perform better.

It all begins with the youth athlete and education. Not unlike protective wear, some of the youth athletes are going to feel self-conscious about wearing certain types of protective lenses. Let us work them through that. Let us give them options. Let us help with the fit. Let us make sure that those glasses are not going to go flying off during a gymnastic event. While running or pole vaulting, let us make sure they are secure on there, and they are at the right type of protective eyewear made of the proper material so that they do not get injured.

Practice conditions are a very important consideration, particularly for the pediatric athlete, because they do not necessarily have control. We talked about this a little bit. The coach is going to tell them that they have got to go out and practice or even though the gym is only 50 degrees, they cannot wear sweatpants or a sweatshirt. We need to educate the athletes as to what appropriate practice conditions are. We need to educate the parents as to what appropriate practice conditions are. We need to also be ready to intervene ourselves as to appropriate practice conditions.

The same thing as temporal aspects of fueling. I worked with a team not too long ago that would not allow sips of water in a four-hour span. They said it decreased performance. The coach said, so the athlete has no control in other words, the youth athlete. We need to empower them, but we also need to be there to protect them and educate the parents so that they can better protect their children. Sometimes they are just doing what the coaches tell them to do as well. 

That moves us on to our hydration of males versus females. What about the youth athlete? We know that women have a lower sweating rate than males. Same thing for the youth females. We know that there is a sex difference in renal water and electrolyte retention. Women are at greater risk than men to develop exercise-associated symptomatic hyponatremia. That also applies for the youth athlete. Just because they are young, it does not mean they can always acclimatize adequately. Just because you are young, it does not mean we have a level playing field for males to females. We need to make sure we are offering proper hydration to these youth athletes, educating them as to proper hydration, educating the coaches and the parents. I am not going to say that too many times at this lecture because I really want to drive home the fact that we need to protect these youth athletes.

Here is interesting research in 2021 by hydration and adolescent athletes that was put out. The results showed that 20 to 44% of the youth athletes were identified as hypo-hydrated, with 21 to 44% and 15 to 34% of athletes commencing low and high intensity training in a hypo-hydrated state. This is done with elite level athletes here. They notice that a third to just below a half of them are all exercising without enough hydration. Let us think about, physiologically, what that does to the fascial planes and the ability for fascia to compensate and glide because that needs to be hydrated. Let us talk about metabolically what happens to these athletes out in the heat, that are under hydrated. Everything is going to go back to education and empowering you to empower them as to adequate hydration.

Relative rest is an important term for the youth athlete as we are trying to get them through a care plan. What we need to do sometimes is make sure that we maintain training, but we might have to be a little creative. I like to think this is the artistic component of working with an athlete. It is how can I keep them kinematically trained? How can I maintain kinesthetic awareness, balance, proprioception, and strength while working through an injury? It is easy for me to send somebody home in a brace and say, “Do not do anything for six weeks and come back.” But is that really the right way to do it if we want to send them back to sport without a chance of re-injury? It really is not. We need to be a little bit more rehab-savvy there and we need to think outside the box.

This would be an example of a ballet dancer with stress injury in her foot, that she is not able to bear weight. We can have her do a dance class on a what we call ballet mat and have her do them, so that she is not putting weight on her feet. We can put her in a pool. Understand that we have to allow healing of the injured area but let us cross-train all the areas so that we do not lose strength, we do not lose tendon girth, and we do not lose proprioceptive and kinesthetic awareness.

When we work through this art of relative rest, what we have to decide is we have got to decrease the duration or the intensity and type of exercise or the number of repetitions. It might just be that simple. It might just be that you have got to cut back 50% on training. However, we really need to consider the injury, the safety of the athlete, the type of injury it is, and the likelihood of it getting worse if we do not stop activity. This is very much an artistic component and really, as you work with athletes more and more, learning what is appropriate. When in certain injuries, I need to pull back on. Some injuries I can still train through but decrease my intensity.

Understand when can I switch to non-weight bearing activities in order for them to get better? Can I cross-train the upper body while the lower body is healing? What about visualization? Visualization is huge for maintaining performance. Then some type of sport participation — watching practice. I like to get them to practice, sitting on the sidelines, listening to the coaches’ feedback of the athletes out there, just keeping their head in the game. This is also good for psychological component of healing as well.

When we consider the pediatric athlete as a whole, I want you to come away from this lecture really understanding the difference between the pediatric athlete and the adult athlete. We need to think about preseason screening because we could have congenital anomalies that nobody has picked up on yet that we might find. Also, we need to consider and look at how we might assess an injury differently. Let us talk about growth plates. We talked a lot about that today. In the elbow and around the pelvis, and now, we have an increase in growth plate injuries that are significant. A good number of percentage of pelvic growth plate injuries, such as hamstrings of the ischial tuberosity.

We need to understand these predispositions are also prevalent in certain sports. Males versus females, contact sports versus non-contact sports. Let us look at the parent and guardians. We talked a lot about that.

If we could come away from this lecture with anything, I would really like to resonate in the fact that we have a responsibility to educate the parents and guardians towards good practices at practice. What is a good environment for practice? When is their athlete hydrated? When does your athlete adequately fed? Different types of nutrition. What about footwear that we talked about? Practice environment, coaching situation.

We need to think of all these things as we consider our athletes. We need to educate those athletes that they take control of their bodies and that they can learn how to care for themselves. The safety of the athlete is above everything else. It is all about preventing injuries. That comes with educating the parents, the coaches, the guardians, and the athlete, and cross-training them so that when we return them to sport, we return them stronger than they were before. We have some guidance for the healthcare team. This means that maybe we need to educate the healthcare team as to what is happening because we have seen breaks in that chain as well.

Thank you so much for taking the time to learn about the pediatric athlete with me today.

If anybody has any questions or issues, you can find me on my contact details below.  Good luck getting your ICSC.

Email: DrCFoss@gmail.com
Instagram: @DrChristineFoss

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English Direct Download PDF ICSC09 _Section 4_Differently Abled Athlete

ICSC Culture Diversity Module 09
ICSC09 _Section 4_Differently Abled Athlete
Instructor: Anne Sorrentino
Video Lesson: 34:25

I am Dr. Anne Sorrentino. I am a sports diplomat certified by the American chiropractic board of sports physicians and will be presenting this class for you. Special populations by definition are populations that require more healthcare or healthcare services than the general population. This need for greater healthcare services among these populations is generally more costly to the system, by maintaining good physical activity and keeping the body in tip-top shape or being aware of what we need to be looking for in these populations, we can help reduce healthcare costs and provide much better service to our patients.

There are several special populations considered in sport; paediatric adolescents, the female athlete, the senior athlete, the differently abled athlete, and there’s also special disease states in sport and ultra-sports. In this lesson we are going to cover the differently abled athlete. The guidelines that we are using are the CCSP Program Guidelines, where we will cover the pre-exam a little bit in Special Olympics. We will not cover the pre-participation exam. That is a separate class, but we are also going to look at the overview of the different types of athletes we may encounter. Yes, you are seeing a picture of Nitro Circus out there and we will talk about that too. According to the Academy of Paediatrics, everybody should have the opportunity to participate and compete in sporting activities. Increased participation in those physical activities and competition still should exist for those that have physical challenges. There are several groups that exist to provide some form of competition for those special populations.

Sports participation benefits. If we compare the differently abled athlete with inactive peers, we will still see some incredible benefits. We have an athlete with paraplegia. They are going to see fewer pressure ulcers because they are moving around, perhaps in their wheelchair. Fewer infections because they are keeping their immune system high and then there is a lower likelihood of hospitalization. Athletes that have limb deficiencies, have improved proprioception because they are constantly challenging it with a sporting or a physical activity, and as a result of that, they keep their muscle strength high and can see an improved proficiency using whatever prosthetic devices they need to, whether working on balance or just your muscle strength.

You will see some of the same benefits that other athletes are going to have, with a differently abled athlete, just by some physical activity. They are going to see increased exercise endurance as they will be working aerobically, so we are going to see an improved cardiovascular function. Their muscle strength is going to be much better. Can you picture a wheelchair athlete constantly pushing that?

Many of these athletes will do a 26.2 marathon. That is a lot of upper body strength just to push that through in an amputee, but they will still be challenging their other leg and building muscle because that leg needs to carry them through if they are using one leg only. We have flexibility, balance, motor skills, but one of the most important things, and we see this through sporting activities for everybody is improved self-esteem. As we are learning, we can do things which therefore reduces our anxiety and depression. When realizing we can get out and participate in something to the best of our ability and have fun.

You may have heard a little bit about the Special Olympics and many of us may have even volunteered for the Special Olympics because they can be done regionally. They can be done in a state area and there is even National Special Olympics and we have the Paralympics, which is a division of the USOPC, and they have the governing rules and inclusion criteria for these events. The Special Olympics start with people at age 8.

I remember volunteering at Stony Brook University back when I was in high school. It was amazing what these children could do because I remember working with the 12-year-old age group and just the excitement of throwing a shot put or rolling a Croque ball or something like that. It was just so much fun. They are so appreciative, but to participate in any of these events, PPEs, the Pre-participation Physical Examinations are required and for eligibility, they are required every 1 to 3 years.

We have International Paralympics, and these are athletes also with physical disabilities, but they are categorized into one of 10 eligible impairments and the IOC determines this. These are assigned numerical rank or grading to a level of disability for fairness because you have some people that have more challenges than others, so you must make the competition as fair as possible. In the International Paralympics, the competitions are every 4 years, there are 29 sports. They are usually held two weeks after the regular Olympics. We just finished the 2022 Beijing, the winter games and the Paralympics was a few weeks later and they have sit-skiing and they have some other competitions. I was very fortunate to work the Dew Tour Copper Mountain this year.

They had the adaptive ski course where the skiers would come down and it was a slalom-type course, and it was incredible to watch these athletes perform, some of them qualified for the Olympics through this because the Dew Tour happened to be an Olympic qualifier. There are 6 winter sports and there are also summer sports. I cannot remember her last name, but there was an athlete who was a dual competitive athlete. She would compete in cycling in the winter in the summer games and skiing in the winter games. Those are some cool things to watch, but there are national sports organizations for adaptive sports contacts, and I have put down their website on this slide for you, so you can go back and take a look and see if any of these are anywhere near you, where you can participate or volunteer.

Question 1.
We are going to set a timer. This is your first question to compete in the Special Olympics. How often must an athlete have a PPE? You have 10 seconds to think of the answer.

Answer: It is every 1 to 3 years. The differently abled athlete must go through a comprehensive screening, but similar to a PPE, you are going to cover all the regular systems that you need to go through. I believe there are 12 systems you need to check. However, you will also tailor it to the disability or condition, and you need to identify predisposing conditions or comorbidities, which is not unusual in this population, and you must provide a needs assessment. Is there something that can make it a little easier for them to move or handle the situation? There are new crutches coming out. There are new springs coming out for prosthetic devices. There are better wheelchairs being developed.

I have a patient who has Multiple Sclerosis, and I am inspired by what that wheelchair can do. Technology keeps improving for this population and we to determine what their physical ability and limitations are. What is something that is not going to happen? What is something that can be on the horizon? What is something that they can do right now?

We want to look at the range of motion, but the flexibility of the extremities in the trunk, if we have somebody that is very strong in the upper body, we know that we must keep that upper body strength because that is what is propelling them forward because perhaps the lower body is not functioning the way it needs to.

We need to make sure they have the strength and have symmetry going on with the strength. We do not want a gross difference between the right and the left arm, even though one side will be dominant. What is their strength? Can they stand on that one leg? Can they stand on the leg for 1 minute, 5 minutes, 10 minutes? Balance and equilibrium skills, postural discrepancies. If you have someone who has only one leg, you need to keep that leg in tip-top shape. Otherwise, you will start to see some mega problems, sensory discrimination, and circulation issues.

The athlete needs to be able to feel down to the joint, and make sure you are checking their pulses and those are within the normal range for that individual. You also want to look at rhythmic and coordination skills, and visual and auditory accuracy. Visual, we will discuss a little more, but it is critical that they can see, what they could see last time. Make a note if anything is starting to decline, and then inspect the orthopedic and special appliances worn by the athlete. Is it time to get a new one? Is it time to upgrade? Because something new has come out, things you want to check.

There are common issues that need to be checked because 12% of the structural cardiovascular abnormalities are seen in this population, and there is a high risk for sudden cardiac death, so make sure you do a good cardiac exam. They may have decreased cardiorespiratory abilities even when there is not a congenital cardiac abnormality, an anomaly that is there. Double-check and make sure you put them through me good training for that. Because now, we have considered using the pulse oximeter as a vital sign.

Pulse oximeter has been more common since 2015, but now with COVID, everybody has a pulse oximeter. Make sure that it is working properly.  You might want to test them when they are doing an activity and make sure their oxygen output is still high.

Then again, you will probably refer out for extra cardiovascular testing because you have covered your basics, not finding something, now go out to your scope.  Send them to someone who is an expert in that field. Ocular function, 1/3 of this population have ocular issues, whether they have poor visual acuity, astigmatism, strabismus, basically just poor visual acuity. You need to make sure you are checking their eyes and running eye tests, smell tests on them, listening to the heart and you want to check their neurological function, compare side to side.

If there is no, second side, you have your baselines to determine what is there, a dermatologic function that is big with certain conditions. You have a genital and the musculoskeletal system, this book on this slide, the Paralympic Athlete was written in 2011. It has not been updated, but there are other books that have come out to help the Paralympic Athlete.

I think they wrote it in 2013, but they did just update it to 2021 sports nutrition for the Paralympic Athlete because you can imagine their protein needs are high, but you also have to maintain and watch with kidney function.  Those are some books which you can get further information.

We will now look at what some of these populations are. We have amputations, blindness, visual impairment, cerebral palsy, dwarfism and we have spinal cord injuries.

When we review the disability and injury pattern, we are excited to say that this population is going to see similar injuries in similar sports to the non-differently abled athlete. In other words, if they are throwing the ball, they are probably going to have similar arm issues. You could be looking at tendonitis, shoulder issues or scapular mobility considerations, and they will see similar injury rates. It is not like they are going to get injured more, throwing a ball than someone else.

You can do your similar evaluations. Use those same ortho neuro tests. Now you might have to extend them a little bit and change it up, but for the most part, you can use those same evaluation forms. You are going to take a thorough history. Some of this is congenital, some was traumatic and you will use imaging as needed with amputations. We often see the same rules in their sports as the able-bodied athletes, but we must look at some considerations. There will be additional care needed for a residual stump, skin irritation from the prosthesis blisters and pressure-related ulcerations are a consideration and sometimes to keep in mind because they cannot really feel the area. They will not notice that something is forming, so you must check.

I have a couple of pictures coming. Phantom pain, we learned about this, any pain that is related to the residual limb. I do not know how long that is going to last. They may feel that that leg is there for a long, long time and they may not feel it at all, but it is a consideration.

What does the limb that is still there need? Based on your standard treatments, they can have soft tissue. You need to treat it the way it needs to be treated. One thing you really want to be careful of is heat-related illness because you are trying to make sure that if they are running out in the sun, they must really keep themselves powered up and they may have decreased sensory through that area. They may not realize that there’s a heat situation on the horizon. These are some stumps, and you can see a dermatosis through here that need to be treated, and these are some of the ulcerations and blisters that can form if it’s not treated properly, and they may not even feel that due to a decreased sensation, that’s why there must be a procedure for it to be checked.

Lower extremity conditions in amputees. Keeping in mind that these are going to pick up the ground transfer, ground reaction forces, and as a result, they will pick it up through direct and indirect load transfer because you have one leg that is hitting and the other one absorbing and one leg that is hitting and you will like them to be hitting equally which is the main consideration. It is not my field to really evaluate that, but that needs to be considered.

Muscular skeletal system, the evaluation of the strength of the commonly injured sites. You could see where you might end up with plantar fasciitis because you are doing so much work here, if the glute is not strong enough there to meet the demand. This glute needs to be strengthened, maybe on the other side too, you must evaluate stability and flexibility. Are you putting too much load on the sound limb? That all needs to be evaluated.

Blindness is a strong consideration because when you have blindness, you usually need someone else that is guiding them, and we see this in the skiing on the sit ski. They sometimes have people say, “Go right, go left, turn this way.” It’s nice because I have been on enough ski mountains where you see the person who is guiding the blind ski down. I just skied Whitefish, Montana, and they have a big adaptive program there. They had very visible bibs indicated clearly to stay away from certain people as they guided their way down the mountain. The last thing you want to do is cut off somebody that cannot see you coming.  The guides are very good about making sure no one comes into the area, but because there is a lack of visual cues, the musculoskeletal system needs to be told what to do. That is why you need somebody with the visual impaired skier.

Sunburn is an issue because they may feel themselves getting hot, they will be getting hot way after the burn has occurred. Something to be careful of.

Question 2. Which differently abled athlete is most likely to experience phantom pain?

Answer: It is the amputee athlete. Cerebral palsy. When I was in the clinic way back in chiropractic college, back in the other decade, I had a patient who had cerebral palsy. She was so thrilled when she was able to do something. If they are walking and on a type of support, it is not unusual to have lower limb injuries at the ankle and the knee because they do not always transmit those ground forces the way an abled position would and that is due to the spasticity. I mean, I used to do a lot of soft tissue trying just to ease some of the spasticity with her and there was gate changes, which set up an unstable situation at the ankle and the knee.

They have very tight lower body musculature, especially the hams and the Gastrocnemius. You want to evaluate for flexibility and strength. You want to see what their active range of motion is and their passive, there will be an exaggerated stretch reflex. Sometimes you need to find the goldilocks approach “Getting it just right”. When I looked to my MS patient, I cannot over-treat her, but I cannot undertreat her and every day is a different day whether related may make a major difference there. Goldilocks approach “not too much, not too little, just right”.

Speech difficulties are an absolute consideration with these parts of this population. There may be decreased strength because they cannot build that muscle, or it is just so spastic shoulder, wrist, and hand issues are very common in wheelchair use and there is motor control and hand-eye coordination and depending.  This one you can see there is a high-level functioning, he is on a tennis tour, but there are all sorts of other things that can happen. You must evaluate for the risk to others with a racket or with a stick because can they control that? Does the spasticity worsen with certain things, or does it fatigue? Those are all considerations you need to look at.

Down syndrome. When you were in chiropractic college, you learned about AAI, Atlanto-axial instability. It is an orthopedic variant in a down syndrome that carries the most serious potential concerns. It presents in other conditions as well, but the down syndrome is where we think of it right away. As a result, that you need to screen these athletes for AAI because if they have it, they need to be restricted from sports that entail a high risk of head and neck trauma because that’s going to create a catastrophic problem. Most contact sports are where they will be limited, such as soccer, football, basketball, but we also must consider things where they might flip even a forward role could be too much, you have to watch in gymnastics or diving or swimming.

One thing is to get in the pool and start to swim. It is more difficult when they must dive in because of the lack of control of the down syndrome, it is trisomy 21 and that is the most common version you will see.

Weightlifting is a great thing with AAI because 15% in down syndrome have Atlanto-axial stability and that is a ligamentous laxity and you have to be careful. How are you going to raise your clinical index of suspicion? Well, notice these things they are easily fatiguing. The gate is becoming abnormal or is abnormal there is in coordination and clumsiness. They have sensory deficits. We would expect to see spasticity, but there might be hyperreflexia or a clonus. Any of that, you absolutely must make sure that they undergo evaluation for Atlanto-axial instability.

Today, the average lifespan of a down syndrome child is now up to a down syndrome adult or senior at 60 years old, congenital heart disease is present in 40% to 50%, but there are other issues we must pay attention to, where there might be hearing loss, where there might be infections in the ear, vision problems. There may be mental retardation with it, orthopedic concerns. Epilepsy is a high concern with this and as a result with lack of movement and there is a greater risk for obesity. But there are other people at risk for that Atlanto-axial instability that we want to just look at rheumatoid arthritis, achondroplastic dwarfism, Klippel-Feil in an abnormal fusion. In other words, where we have more than two or equal cervical vertebrae.

You have three to four questions you going to ask with AAI, and if they are all answered, no, you may be good to go.

1. Does the athlete show signs of progressive myopathy?
2. Does the athlete have poor head or neck muscular control?
3. Are they bobbling or can they control it?
4. An important one, does the person’s neck flexion allow them literally to just flop and rest on the chest? Yes. I can bring it down there with my mouth closed, but does it just fall there? You want to look at those risks for AAI.

I wanted to put up an x-ray so that you saw what this looked like. You can see in the normal cervical, everything looks lovely, and the minute we drop into flexion. Look at what happened. We just got a big gap in the ADI. We want to look at that. That is not good, so there we have AAI.

Question 3: Which differently abled athlete might you encounter speech difficulties?

Answer: I told you that my patient, I had was a cerebral palsy athlete and she had speech difficulties and it took a little bit till I understood her, and then I was clear with her. Just stay with it and you will be able to understand what they are saying.

Conditions for wheelchair racers. Well, wheelchair racers usually are going to be upper body strength and that is why they are in the wheelchair because maybe their lower bodies are not doing so much. What we are seeing, would be quite logical is a peripheral nerve entrapment for the upper extremities. Now, most common. We will see carpal tunnel syndrome, but let break it down. We are going to have some, all neuropathy at the wrist, and see Guyon canal syndrome, but we may also have median nerve deficits. We may also have radial nerve deficits and keep in mind, there is no rule that just because they are having a problem here that is what it is.  Follow up the arm and see where it is crimping. It could be at the elbow or the shoulder. We might need to give them more scapular stabilization exercises. We need to look for muscle atrophy, and signs of weakness in the hand, put them on a dynamometer, check their grip strength, check for specific sensory nerve deficits. Do we have circulation? Do we have a motor? Do we have sensory? All those things need to be compared side to side. Look at the intensity. If you have never seen a race like this, the intensity is incredible. These athletes are so great.

Dermatologic function. Keep in mind, they are going to get blisters on their hands. They will most likely be wearing gloves, but at some point, you will start to get blisters and abrasions and they fall in with the sit skis athletes as they tip over a lot.  They will be slamming their hand and you could break a wrist with something like that. They are racing against others. There will make contacted with other chairs and be banging into each other.

Let us also consider pressure ulcers because they are sitting for long periods as well as sweating. Maybe, right after the match, they may have a beer with somebody, meaning that could be sitting in sweat for a long while. You may see some shearing and some ulcers from there and that is without even considering the prosthetic devices that they are working with.

Modified seat cushions may make a difference with this, but make sure you keep changing those. Even on my bicycle, there is a Tempurpedic bike cushion. Different cushions can make a difference for these athletes.

The urogenital system, they might have devices in, which are for drainage, and that needs to be confirmed.

The musculoskeletal, we will see tendonitis, rotator cuff issues, pec tightness, because they are in that forward position. We will lose that imbalance of A to P from the shoulder to the chest versus from the chest to the center of the back.  You need to get their shoulders back and you encourage opening that up and strengthening the scapular stabilizers and the lats. You will need to evaluate stability, flexibility, and the commonly injured areas.

Spinal cord injuries, well trauma damage cells within the spinal cord. That is the most common one you will see. We can see spina bifida, determining where the cord injury determines the level of function. Just in terminology because this always gets confused with people.

Quadriplegia involves both lower extremities, but you still have some upper extremity involvement.

Paraplegia involves both lower extremities with little impairment above in the upper extremities.  Down here on this slide, you can see where the spina bifida and they will need surgery to repair it, but that does not mean they are going to be able to walk.

Here on this slide, we have some wheelchair basketball athletes. Then we have somebody coming down, a slalom paralympic skier, and you can see the upper body is good. They are using their arms, look at the two skis on the arm and the sit ski has one ski on the bottom.

Pain, muscle spasms, and sensitivity to stimuli may develop. Of course, they may get muscle spasms. Absolutely because they are working so hard and sometimes load exceeds capacity. You may see secondary medical problems. There will be bladder issues, bowel issues, lung infections because they are not expanding everything and during this lesson we covered pressure sores and shoulder pain.

In closing I would like to tell you about Aaron Wheelz Fotheringham. I encourage you to Google him. https://en.wikipedia.org/wiki/Aaron_Fotheringham

Wheelz was born with spina bifida at age 8, and was living in an adoptive family. One of his brothers challenged him at the skate park to drop in. Wheelz always wanted to be a professional athlete and you can see him flipping.

Wheelz entered America’s Got Talent recently and he had to crawl up the gigantic ramp. One of the men, Ricky, who is the athlete liaison for Nitro Circus was up at the top and carried Wheelz’s wheelchair up and Wheelz climbed up the whole thing, on his back, moving his arms all the way up. He rode the gigantic ramp down and he crashed.

It is not unusual for the athletes to crash sometimes on their first attempt, especially if they have not had enough practice, however Wheelz got up. Ricky went down and got his wheelchair and brought the wheelchair up because Wheelz said very clearly, “No, I am going up again and doing it. I am going to show you all I can do this.” He got all the way up to the top and he rode the wheelchair down and he landed it perfectly, so perfectly that one of the judges was so impressed. She gave him the golden buzzer and sent him right to the finals for that much spirit.

It reminds me of a quote I saw in a hospital the other day that talked about exercising and it said,

“Rule number one is don’t quit. Rule number two, never forget rule number one,”

Wheelz is an incredible guy. He is now 30 years old now and based in Las Vegas.

You will see that these differently abled athletes are not disabled. They might be a little challenged, however very impressive.

Thank you for your attention. I sincerely appreciate you and I wish you the best on your exams.

 

[END]

English Direct Download PDF ICSC09 _Section 5_Female Athlete

ICSC Culture Diversity Module 09
ICSC09 _Section 5_Female Athlete
Instructor: Giselle Foss
Video Lesson: 01:16:48

My name is Dr. Giselle Foss, I am a Chiropractic Physician, Woman’s Work Facilitator, experienced 500-hour Yoga Teacher, and candidate for my Master’s in Acupuncture and Traditional Medicine.

I am here today to talk about Treating the Female Bleeding Athlete (menstrual cycle), so treating your athlete in a way that is in alignment with their body. We will get more into it and way more in-depth as we go through out this course together. It is important to remember that if you have an athlete that bleeds, that has a uterus and gets their period every month, it is not always in the best interest of the athlete to train everyday the same as the day before based on the fluctuation of hormone. That is what this whole thing is about. It is teaching your athlete how to work with their body instead of working against their body.

We are going to start with a little introduction about myself, how I got into this work, and what has inspired me to continue on the path of educating patients and athletes with bleeding bodies on how to move in a way that honors their cyclical needs. I will talk a little bit about big Ideas of menstruation and the menstrual cycle and what a normal menstrual cycle is, because it can look a little different on different people, depending on their hormones and depending on their cycle. We will learn what baseline normal is and do a little fresher on all of the sex hormones that are super important when it comes to menstruation.

We will explore a little bit into my eastern brain and talk about how menstrual cycles relate to traditional Chinese medicine or TCM is the abbreviation. Then, we will jump right into some research on how the phase of the menstrual cycle can either prevent or promote injury in an athlete. We will touch a little bit on fascia and how that changes throughout the cycle and how that can affect your athlete. Talk how birth control affects hormones, and therefore affects your athlete. Touch on how to train your athlete with their cycling body, then, how to teach your athlete how to track their cycles, so that they can move and work out and train in this way. Finally we will do a conclusion and a wrap-up summary of everything we covered.

It is very important to know that in this lecture, I use the pronouns she/her a lot to describe bleeding people. However a person identifies, if they bleed, this is relevant information for them.

Let us start with my story in how I got into this niche-type work of teaching people how to move and helping my patients live in a more cyclical way. I was diagnosed with endometriosis when I was 14. I was brought to the OB-GYN that young because of how a regular and how painful my cycles were. I was put on birth control at that super young age, and I was on it for a very long time. Then when I finally decided to come off as a young adult, everything got worse. What they do not tell you is if things are regular prior to oral contraceptives, they tend to get worse once you come off the oral contraceptive. It is because not only have you never had a regular cycle, but your brain no longer knows how to communicate to your ovaries to produce hormones in the correct cycling way. I began my journey with trying to figure out how to live a life with this crazy irregular menstrual cycle without the help of birth control.

I started being treated by an acupuncturist who also prescribe me Chinese herbs to help regulate my cycle and everything cleared up. The endo went away and everything. I started getting treated by this person when I was in chiropractic school and as soon as I graduated, I immediately went back to school to study Acupuncture and Chinese herbs portion, because I was so interested in regulating cycles and helping people overcome painful periods in a more holistic type approach because there are so many other natural options besides hormonal replacement type therapies. I became, obviously, super passionate about periods, about menstrual cycles, about living in a way that honors your body to therefore help regulate. I started a business and heard the call that I was supposed to do this type work and I followed it. I got a lot of heat and weird looks from people, and I still do when I tell them I specialize in menstrual cycles but that is okay. It is what I absolutely love.

This is the business I first started. I am no longer taking clients online, but basically, I had clients or patients on Zoom. I taught them how to eat with their cycle and exercise with their cycle to help regulate their hormones and honor the changes in their connective tissue, in their fascia, in their hormones throughout every cycle because we are different every single week because of those hormonal fluctuations. This is super important to remember. If you are pushing yourself during times when your literal anatomical structure should not be pushed, it is causing more harm than good. This is when injuries can occur, especially in the athletic population.

This is just a quote that I like out of one of my favorite textbooks. It is the Obstetrics and Gynecology textbook by Giovanni Maciocia. It is a gynecological textbook on Chinese medicine, pretty much. This says.

“The term Tian Gui is impossible to translate because Tian Gui means ‘heaven’ or ‘heavenly’…. The fact that the term for Tian Gui refers to ‘Heaven’ is significant: it refers to the fact that women’s menstrual cycle is influenced by cosmic cycle.” -Maciocia

Why I chose this quote and why this quote hit home to me when I was doing homework one day, reading the textbook and came across, is that menstrual cycles and periods were not always seen as something to hide, something to be ashamed of, or something as dirty. They were regarded as something heavenly, sacred, or from the gods.

In addition to teaching my patients on how to live in the cyclic way to honor their bodies, nurse their injuries, and prevent injuries, I also try to instill this understanding that bleeding, cycling, and modifying your life for your cycle is actually normal, empowering, and amazing because a lot of women have this disconnect between their bodies and what they think is normal. Do you know what I mean? It is important to inspire our patients as we are teaching them these concepts and let them know that your period is normal, it is supposed to happen, it is a beautiful thing.

A lot of times, when they first come to you and you are talking about these topics, especially in an athletic person, they tend to be a little bit shy “Oh, that is weird. I do not really want to go there.” Just gently easing them into the notion that cycles and periods are normal, and it will really help their athletic performance if they connect with these cycles, embody these cycles, and train in a way that actually honors their bodies. It will help their performance through their sport.

This is just a classic definition from Merriam-Webster Dictionary of menstruation. I was interested one day of what the dictionary defined it as. I got,

“a cyclical discharging of blood, secretions, and tissue debris from the uterus that recurs in nonpregnant breeding-age primate females at approximately monthly intervals and that is considered to represent a readjustment of the uterus to the non pregnant state following proliferative changes accompanying the preceding ovulation…”

In other words, menstruation, so bleeding. The active bleeding is what menstruation is, but this is not just the menstrual cycle. This is just one of the phases of the menstrual cycle. When people hear the word menstrual cycle, they automatically think you are only talking about the period. That is not true. The menstrual cycle is the entire month of hormonal fluctuation. Menstruation is just the period portion of this entire monthly, yearly cycling that we do as bleeding people.

Your menstrual cycle is not just your period. There are four phases, which we will go into deeper during this lesson. I like to argue five, but the point is there are different phases.

Educating your athlete in this is the key, they might not realize that their period is more than just their period. It is they have to honor their body in all of the phases in order to regulate their hormones and train for their optimum performance. In the same way, because we have these phases, bleeding bodies are not the same every week.

As our hormones rise and fall, our connective tissue changes, our sex drive, energy level, appetite changes. So much changes from week to week to week and that is normal for a bleeding person.

Females are not built like men. Men have a pretty consistent rising and falling of testosterone throughout the day, whereas women have significant rising and falling of different sex hormones that shift from week to week to week. Hormones are in charge of basically all of your body’s processes. It would be ignorant to think that sex hormones only play a role in getting pregnant or getting your period, they influence every system of your body.

What is a normal menstrual cycle? This is like the gold standard normal menstrual cycle. There are outliers, but this is basically what you should go by. I like to teach that a normal cycle is between 24 and 32 days, research shows that, yes, within that range, that is a normal cycle. However, whenever you read things on the internet or they teach you in basic anatomy and physiology book, they say that a normal cycle is 28 days. Yes and no.

It is very rare that most women have a perfect 28-day cycle. That 28 days can fluctuate from month to month, depending on stress levels, diet, exercise, or life events. Just because maybe your patient does not have a 28-day cycle does not mean it is not normal for them. You must know what their normal is.

For me, my cycles are about 31 days in length, and that is normal for me. You want their baseline in order to gauge if they are in that normal range. Twenty-four to 32 days is good to go.

Bleeding should last only three to five days. Blood loss is about from 10 milliliters to 80 milliliters. Eighty milliliters are obviously the high end of normal. I would argue that that is too much blood. This is just what research shows. I always like to tell my patients that about 3/4 of a menstrual cup full for the entire period is what is normal. Any more than that, you tend to be losing too much blood. Too much blood loss in athletes, anemia, fatigue, things like that, so once they come out of that period phase, if they are losing too much blood, it is hard for them to recover because they do not have enough iron. If your athlete is bleeding a lot, say 80 milliliters, you definitely want to, if it is within your scope of practice where you live, get blood work and see if they are anemic and recommended good iron supplement to give to them to help with that.

Hormones control almost every aspect of our human experience; from our mood, to our libido, hunger, energy levels, everything in our human experience is because of hormones. This is a mnemonic that I use to help me remember the order of which the hormones rise and fall through the duration of the entire menstrual cycle in my bleeding patients.

I use the mnemonic HELP. H stands for hormones, so just general. E is estrogen. That is the first hormone to rise. At the top, the second hormone to rise is the L in HELP for luteinizing hormone/follicle stimulating hormone. We will learn about it, but the two go up together. That is your fertile window. The last hormone to rise during the course of the menstrual cycle is progesterone. It arises at the very end. That is our P in HELP.

Remember that mnemonic and write it down. It comes in huge help, especially if your athlete, during the first 10 days of my menstrual cycle, or say they start tracking their cycle and they report, “From day 10 to day 14, I feel horrible. I am cold. I am nauseous. I feel heavy.” That is an estrogen thing.

Maybe, running a blood panel and seeing where their estrogen levels are at that base of their cycles. There are normal ranges for hormones during different phases. I will not get into that in here because this is not really about blood work, but yes, investigate that. Blood work is recommended if there are cycle-related complaints. In addition to that, Chinese medicine and herbs is helpful for cycle-related complaints in specific phase stuff. You can always recommend that to your patients.

This beautiful chart which I absolutely love because it shows everything about the cycle in one picture. I am a visual learner, so I like to share charts, pictures, and stuff when I teach.

This shows the follicle maturing throughout the phase. This is your basal body temperature. We will talk about that in how to teach your athlete how to track their basal body temperature, if they are interested. These is your FSH and LH hormone. Level is rising and falling. See the peak in the middle. We will talk about that.

Estrogen and progesterone, we talked about in our mnemonic that estrogen is the first one to rise as you see it. FSH and LH are the second. They meet in the middle rising, and then progesterone is our last, following that until we fall. At the end here, we will get her period when the hormones fall.

The last little section here is demonstrating the endometrium layer. The endometrium is the layer of the uterus that sheds and flows off for menstruation to occur. This is showing that as progesterone is dropping, we reach the bottom, the lining of the uterus is shedding. It is bleeding because this is day one. As the period ends, the lining of the endometrium rebuild itself until it reaches its peak agai at the end of our progesterone peak. As progesterone falls, it falls too, and we get our period.

Let us go into some hormone detail here. I just put some basic concepts in, but I did not go all in depth. There are so much to sex hormones. There is so much research out there. If you are interested in specific hormones, I definitely recommend you delve a little deeper into that. Here are some basic ideas that will really help you understand the cycle and what hormones are responsible for.

When we are talking about estrogen, there are three types of estrogen in the bleeding body. There is estriol, estradiol, and estrone. When we are talking about estrogen, it is really these three types of estrogens. Estrogen is most commonly produced by your ovaries, which sits connected to your uterus by fallopian tubes. Small amounts can also be created by your adrenal glands as well as fat cells. Because of this, it is very important that we have our bleeding athletes on diets that include good healthy fats like avocados and fish. If they do not eat that, omega-3 is to support this healthy estrogen productive production through the first phase of our menstrual cycle. A healthy follicular phase, which is where estrogen rises, sets the rest of the cycle of birth success. If there is a problem in the follicular phase, there will probably be an issue at ovulation and definitely reflected in the period itself.

 

The main role estrogen plays in your menstrual cycle is it helps your uterine wall regrow after you bleed, so that an egg may have a soft place to implant. If the wall, the line, the endometrial lining is not really grown to like par, the embryo, the fertilized egg cannot safely implant into the wall. It needs a soft cushy area to burrow into to get stuck there. This is obviously something that could be a miscarriage risk or anything like that. We really want to make sure that estrogen is good and supported by good fats. We know that it is the first hormone to rise in the beginning of our menstrual cycle. It rises around day 8, depending on the person, depending on their normal cycle.

Just some few things that estrogen does, it keeps your heart healthy by raising HDL. This is the good cholesterol. It keeps your bones strong. You will notice that post-menopausal women start to get osteopenia, and then if it progresses, to osteoporotic. That is because of the drop in estrogen. Once estrogen drops, your bone density tends to drop as well. That is why it is important to keep your menopausal and postmenopausal women on weight-bearing exercise regimes to help keep their bones strong. It affects your mood. It affects your cognition. It affects your hair and skin. It affects breast tissue.

Number 2 is our L in the HELP mnemonic. This is our luteinizing hormone. When your body is ready to ovulate, which ovulation is your fertile window. When ovulation happens, this is the only time of the month, you can get pregnant. A bleeding person cannot get pregnant. The LH and FSH need to spike in order for that to happen. Your pituitary gland produces luteinizing hormone, then it releases it, which causes a surge and triggers the release of an egg from your ovary. This is why you can get pregnant.

If your luteinizing hormone does not rise. There is no egg released from the ovary. Again, conception cannot occur if there is no egg for the sperm to meet. This is just a little picture. From your brain, your pituitary produces the LH. When it is around mid-cycle when you are going to ovulate, it releases that LH. It causes a surge to the ovary, which causes the release of an egg, which therefore can get fertilized. If it does not, it will then leave the body with the shedding of the endometrium when the period occurs.

FSH or follicle stimulating hormone rises at the same time as LH. This still counts as our L in our HELP mnemonic. There is a lot of similarities between FSH and LH. Again, it is essential for ovulation. It is also released from the pituitary gland, and basically, the job of FSH is to get the egg ready for ovulation. It stimulates the growth of a follicle in your ovary. This is essential.

Follicles are tiny fluid-filled sacs that live inside of your ovaries and secrete hormones that influence your menstrual cycle, like estrogen. Each follicle has the potential to release an egg during ovulation. If LH does not rise and trigger that follicle to get ready to release an egg, your estrogen levels will be off and other hormones we will learn are also produced in a follicle in the ovary as well. It is very, very important that these ovulation hormones. Even if your athlete is not trying to conceive, they are trying not to conceive, it is very important that these still rise in a healthy way if they want their estrogen secretion as well as other hormonal production and secretions to be healthy and normal. This is essential.

Our last hormone to rise in our cycle is progesterone. The job of progesterone is to get the uterus ready to get pregnant. It makes sure that the uterus is ready for implantation and progesterone is dominant in the second half of your cycle. It helps feeling calm. It helps reduce anxiety. It helps you fall asleep. It helps protect your breasts and uterus from cancers. It is created in the corpus luteum. It is in your ovary. It is created at ovulation. Even if your athlete is not trying to conceive, healthy progesterone levels are important for more than just preparing your uterus to have an embryo implant. It helps with the calm, the anxiety, and fall soundly asleep at night. You want to make sure your athlete is in a good mental health space when they are training, especially when they are performing. You want to make sure they have a good night sleep. Very essential for these hormones to be rising and falling in healthy levels.

This is not in our mnemonic. This is my sister who was a gymnast for a very long time. Testosterone — when we think of testosterone, we normally think of males because they are more testosterone-dominant, whereas we are estrogen and progesterone-dominant. Bleeding people have testosterone as well. It is produced in our ovaries as well as our adrenal glands. We do not have nearly as much as testosterone as males have but having normal testosterone levels in the bleeding person is extremely important. It helps with our bone strength, our brain speed, and our good moods. It helps us with confidence, energy, and libido. All of that sounds amazing. It is super important to have these hormones at healthy levels.

Relaxin — this is a hormone that we are probably going to focus the most on during this lecture because this is what most of the latest research focuses on when they are looking at cyclical connections to athletic injuries.

Relaxin — huge, huge hugely important in the female body. It is most predominantly known for facilitating vaginal labor. When relaxing is released, it increases the laxity of the pelvic ligaments, allowing for the child to pass through the birth canal. It is a member of the insulin-like family. There are three types of relaxin. Relaxin-1 and 2 are what we really care about. They regulate the expression of collagen, fibroblast metabolism, and changes in the corpus luteum and other layers of the ovary as well as the endometrium. Relaxin-2 is present in non-pregnant females and linked to cyclical changes of connective tissue that alter the mechanical properties of ligaments, tendons, muscles, and cartilage. This is primarily produced by the corpus luteum, so in the ovary. Relaxin-1 is important, but relaxin-2 is our big key thing to focus on here when we are talking about training the bleeding athlete. Relaxin-3 is specific to the brain. It is also important, but we do not need to go into it for this specific topic.

Thyroid hormone is, arguably one of the most important hormones when it comes to regular menstrual cycles because when your thyroid levels are off, all of your hormone levels are going to be off. If you are feeling some intuition about maybe your athlete’s thyroid is not working an optimum levels, I would definitely investigate that and order blood work. When you do order blood work, you need to make sure that you are ordering T3, T4, and TSH levels. You need to see all three thyroid levels to actually get the full picture. If you just have one or two of them, it is not good enough and you are not investigating far enough for your athlete in the functioning of their thyroid.

T4 is the inactive form of thyroid hormone. It needs the help of your gut, kidneys, and liver to convert it into the active form, which is T3. T3 manages your mood, energy, and Metabolism. If your T3 is too low, it can cause irregular menstruation. Low thyroid hormone is associated with infertility, miscarriages, digestive disorders, hair loss, and skin disorders.

Yes, if your athlete that you are working with, and you are teaching them all these cyclical concepts, if they are unable to regulate their cycle or they come to you and they are saying their cycle has always been irregular, or they do not know why, maybe they are presenting thyroid symptoms, whether it is hyper or hypo, definitely order blood work for T3, T4, and TSH levels, as well as making sure you check for anemia and stuff like that.

This is my favorite thing to teach. It is the phases of the menstrual cycle. In order, it is your menstrual phase, which that is your bleed; your follicular phase, in which estrogen rises; ovulation, which is the midpoint where FSH and LH rise; and our luteal phase is our progesterone rising. Those are the four main phases of the menstrual cycle. You cannot properly teach a patient about their menstrual cycles or training with their cycles if you do not educate them on the specific phases.

We are going to tap a little bit into my Chinese medicine eastern-sided brain. This is my favorite thing to teach. I am super passionate about this. I find it super interesting when I started learning about the Chinese medicine perspective of menstrual cycles. It just inspired a lot of passion in me and a lot of understanding about my body and how things would change during different phases of the cycle. Let us get into that. In Chinese medicine, each element corresponds to a menstrual phase, a color, a flavor, a season, and a form of movement, in addition to other things. Let us break that down and make some sense out of that sentence.

We are a microcosm living within a macrocosm. This is something that we say in TCM practices all the time. This is what our original text, that all Chinese medicine was based off of, boils down to. What this means is we as the human, our bodies are a tiny little universe that has their own season. Things change in a cyclical way. Living inside of the macrocosm, that is planet earth, which has its own big seasons, like spring, fall, summer. Things like that. It is important to have those things.

This is just basic theory. I am not going to go too much into it because it can get quite confusing. When we are talking about elements in Chinese medicine, this is how we tend to set it up with this star. We call this the controlling cycle, the insulting cycle. We are not going to get into that, but this is how we look at our elements. We look at it in a star because it helps us see the order in which each element can affect each other respectively. We are not going to go into that, but we are going to go into the element. We have fire at the top of our star, followed by earth, metal water, and wood. Each of these things break up into phases of anything. Macrocosmic seasons, microcosmic seasons, emotions, movements — we are going to go deep into that

We are going to start with number one or phase 1 of the menstrual cycle. This is our menstrual phase. This is where your athlete is actively bleeding. This is when they are on their period. The first day that you start bleeding is day one of your menstrual cycle, and then you keep counting up in numbers until you get your period again. When you count your menstrual cycle days, it is not just the days you have your period. It is all the days from period to period. It should be between that 24 to 32-day-window that we said. The fall of progesterone triggers are endometrium to start shedding, and this is our menstrual blood.

In the Chinese medicine sense, the element associated with menstruation is water. This is our inner winter. If you are a bleeding person watching this, it makes perfect sense because when you have your period, you just want to rest and be reflective and lay on the couch, watch TV, and eat snacks. Energetically, that is exactly what you should be doing. This is a time of rest and reflection. The emotion associated with menstruation, from a Chinese medicine perspective, is fear. There are two organs that are associated with each element. For this element of water, our inner winter, and our menstruation, it is kidneys and urinary bladder. The flavor associated with this is salty. That makes sense to me because water in the ocean is salty. Kidneys and urinary bladder, I think of electrolytes salt. That makes sense to me.

Your athlete, during this time, should not be training hard — gentle stretching, slow walking. I understand that having an athlete do only gentle stretching or slow walking for the entire phase of their menstrual cycle is probably impossible. They want to get back to training, so maybe recommend maybe day 1 and 2. If they are insisting that they even work out on day1 or 2, or they have a meet or competition on day 1 or 2, maybe instruct them to take it a little bit easier and make sure that they have more than enough food, nutrients, and water to support them losing blood. I always tell my patients that if you were bleeding this much that we lose from our menstruation from any other part of your body, you would probably go to the hospital. You would not be on the stair stepper for 40 minutes. That opened their eyes.

We are actively losing blood, fluids, and iron when we are bleeding. Our body is not capable of working that hard. You are just depleting yourself. Giving your athlete permission to take two days to just take it a little bit easier can be really liberating, and their bodies will feel so much better when they are done bleeding because they are not absolutely drained, depleted, and exhausted. During this time, it is important that your athlete only eats foods that are cooked and warm. Cold foods can give them more cramps and lead to other things from a Chinese medicine perspective. I always recommend bone broths, maybe chilis, stews, soups. A lot of my athlete patients say they do not eat a lot when they are bleeding because they are nauseous. I always recommend soups and broths. It tends to be my go-to that people really like.

Phase two is our follicular phase. This is the time from when you stop bleeding, so your period ends, up until you ovulate. Up until that FSH and LH surge, this is your follicular phase. During this time, you might notice a rise of energy, productivity, and inspiration. This is when you want to tell your athlete to optimize on their energy. This is the most energy they are going to have throughout their cycle. The energetics during this time is rising. It is our inner spring. You want to plan, prepare, and get organized. Our estrogen is rising. Our follicles in our ovaries are growing here. As the follicles mature, they start increasing the amounts of estradiol that are being released, new endometrium layers being formed, and estrogen stimulate the cervix to produce fertile cervical mucus. This is day 5 to 13 in a perfect world. As you can see, a lot is going on in your follicular phase. Remember when I said if your follicular phase is off, the rest of your period is probably going to be off? This is why. Your follicular phase really sets you up for success.

Let us look at it from a TCM perspective. Inner spring, we said that. The element associated with your follicular phase is wood. The emotion is anger. The yin organ is the liver. The yang organ is the gallbladder. In our foundational text, it says that the liver controls planning. The liver is the organ that is working overtime here. It is the most predominant. This is the time when we want to plan. Maybe your athlete gets really inspired to plan their workouts and their training schedule during this time. You should encourage that. Give them ideas on how to create that training schedule in a way that honors the rising and falling of their hormones.

I know for a lot of my patients, during their phase, they whip out the highlighters. They whip out their calendar, and they are writing their exercise program on their calendar based on their menstrual cycle. It is always really inspiring and fun to watch. It feels good for female athlete to know when to work with her body. They will notice their training will be better as they do this because they are not exhausting their bodies in times when they should be resting. They are optimizing on their energies in times when they have the energy to optimize on.

Exercise for your follicular phase from a Chinese medicine perspective again, this is the time when you want your athlete to do more yoga and be stretching. This is because in our ancient text, it says that wood should be flexible in the wind. The element is Wood, and we know in the actual macrocosmic season of spring, it is super windy. Marches in like a lion and out like a lamb is the saying. So we want the branches of the trees, wood, to be flexible, so that in the wind, they can sway. They can go with the wind instead of snapping and breaking. Same thing here. I did not write it in the slide, but the tissue associated with the liver as well is the sinews. The connection of tendons and ligaments to the bone. The stretching makes sense during this time because you want to keep those areas lax to prevent rupture or sprains, anything like that.

The energetics of this phase is rising and productive because during spring, the energy of the earth is coming back. The energy of our body is coming back after losing so much blood. The flavor is sour. Maybe you tell your athlete to drink lemon water during this time. Nutrition is to eat light — nut, sprouts, and salad. Whenever it comes to nutrition in Chinese medicine, we always recommend eating the food of the season. We are not going to go deep into this because it can get mind-boggling, but if this is your inner spring, you want to eat more like you would that things that would grow naturally in the spring like nut, sprout, and seeds. If it is the dead of winter and you are eating these things, that can cause more harm because our microcosm is affected by the macrocosm. If you have any more questions about that, you can send me an email. Just tell your athlete to eat lighter during this time.

Ovulation — when the body has reached its peak estradiol levels, a sudden release of luteinizing hormone from the pituitary starts ovulation. This is when your athlete is most fertile. This hormonal surge only lasts about 48 hours. The release of LH matures the egg, starts the process to release an ovum. If it is not fertilized, it dissolves in the fallopian tube and then you bleed it out with the endometrium layer. During this time, there will be an increase in the libido as well as an increase in confidence. This is our energetic peak. In a perfect world, if your athlete had their meet or competition on the day of ovulation, that is the perfect day to compete because they are the most confident, most energetic and the most willing to go out, be social, and do things. This is the most energetic, the energetic peak of the cycle.

This is our inner summer from a Chinese medicine perspective. The element of fire. Summer is hot. Fire is hot. Emotion is joy. The yin organ is the heart. The yang organ is the small intestine. The exercise recommended for bleeding people during this time is a heat workout.

What I mean by that is more cardio. The element of fire rules the heart. You want to make sure that your athlete is upping their cardio during this time to help exercise that heart organ. The energetics during this time is up and out. Like I said, this is our energetic peak. The flavor is bitter. Nutrition during this time is that that would be harvested in the summer, so fruits and veggies. Please do not eat a watermelon in the middle of January. We are a microcosm within a macrocosm. Yes, more fruits and veggies are great during this time, but make sure if it is cold out still, they are cooked. Do not eat watermelons in the middle of the winter. That is used for heat stroke as a Chinese herb, and it makes you too cold. Play with what you can incorporate into your diet that makes sense for the season that you are in now, as well as the season of your internal menstrual cycle.

An interesting point here is a lot of OB-GYNs recently, fertility doctors, and MDs are recommending their patients who are struggling with fertility to try the keto diet. I understand why they would want them to be on a keto diet during the follicular and ovulation phase because you are eating lighter. You have more energy naturally. You really do not need carbohydrates in your diet here. However, I feel like as a bleeding person, it is important to have carbs, starches, and extra calories in your luteal and bleed phase because you need the energy. You need the calories to prepare to lose all that blood. If your athlete is doing the ketogenic diet during follicular phase and ovulation, that is fine. During luteal and your bleed, you need the extra calories, so definitely give them permission to eat the pasta. Do you know what I mean?

Our last face here, is our luteal phase. This is from when your ovulation ends. After that 48 span of time to your period, this lasts about 14 days in a normal cycle. There are always outliers. During our luteal phase, this is when our energy starts to decrease. This is perfectly normal and exactly what is supposed to happen. You want your athlete to allow their body to move a little bit slower and allow them to give themselves brakes and more rest throughout the day.

Our progesterone rises as we transition into this reflective phase and the corpus luteum produces our progesterone here. This is the luteal phase when a lot of your athletes will say like, “Oh, I am PMS ing.” This happens during the luteal phase. 

This is our inner autumn from a TCM perspective. The element associated with this is metal. The emotion is grief, which for me, when I learned that the emotion associated with luteal phase that is normal to be expressed during this time is grief, it really made sense for me from a PMS perspective. A lot of my patients, friends or people I know that bleed, often say “Oh, I am PMS ing. I am so emotional. I cried for no reason.” I would argue that that is normal behavior because grief is supposed to be expressed during this time because the organ of the lung grows grief in Chinese medicine. That is the organ that is the most predominant here during this phase. The yang organ is large intestine.

During this time, you want the exercise for your athlete to include more weight training. This is because our estrogen is falling here. Just like in a menopausal and postmenopausal woman, when are estrogen levels decrease, you want to make sure that you are doing weight-bearing exercises to keep your bones dense and strong. The energetics are falling, which is why our energy decreases. The flavor associated with this is spicy. Nutrition during this time is root veggies and hearty foods. You want to make sure everything is warm and cook during this phase. You want to make sure you are eating more than enough protein because you are about to lose a lot of blood and you need to make sure your body is equipped to do that with enough calories and with enough nutrition.

Back to the beginning again. At the very end of our luteal phase, our progesterone levels will drop off and allow our bodies to start bleeding. This is our luteal phase peaking, falling, and we start all over again and again and again. The cycles continue from the first time we get our period at menarche until we hit menopause. If you are pregnant or on birth control, you are not cycling.

Before we started breaking down all the elements and how they fit in their phases, we said that there are five elements. There was fire. There was earth. There was metal. There was water. There was wood. We talked about four of those elements, but the fifth was missing and it is earth. This perplexed me for a little while when I started really getting into the TCM theory and relating it for my bleeding patients. Where does earth fit? It does not make sense. It does not fit a perfect phase.

This is the star we talked about. I drew a little differently with earth in the center. This is how we actually originally learned or I originally learned the elements in my acupuncture schooling. It was with earth in the middle, but when we learn about the controlling cycle and stuff like that, we change it to the star to make it easier. I came back to my roots here and I was like, “Oh, it is because earth is affected by all of the elements. Earth is not a specific phase. It is the in-between. Between fire and metal, there is the space where earth can come through. Same thing between metal and water. This is the earth. I have been calling these the In between phases. They are just as relevant as the main phases.

The in-between — in Chinese medicine, the Earth element is associated with a late summer. The emotion is worry. The yin organ is the spleen and the yang organ is the stomach. In Chinese medicine, spleen and stomach is our digestion. Very interesting as we now know in Western medicine, research shows that, I think, 80% of our serotonin is produced in our gut. When our digestive system is not working that well or does not have the nutrients it needs, things like anxiety and depression can occur. That has been scientifically researched. I think it is very interesting that the emotion is worry and the organs are spleen and stomach, which, again, is our digestive system because if the digestion is not good during this time, if we are eating foods to support it during this time, our athlete, our patient can start worrying and feeling anxious during these in-between phases. 

Earth, the tissue associated with it is not written here, but like the liver and like every other element that has a tissue, it is muscle, especially the leg muscles. The exercise associated with these in-between phases is stabilizing and strengthening leg muscles. The energetics is holding. The flavor is sweet. You want to make sure you are eating mindfully during this time to support that spleen and stomach and to help alleviate some anxiety or worrying during this time. For a lot of my patients, it was pretty empowering for them when they realize that this in-between, this late summer phase was there because when they started tracking their cycle, they would be like, “I get what I am in my main four phases, but in-between the phases? I feel weird and have weird days.” That is because they are in the in-between phase and they need to eat better and work out their leg muscles.

This is just a little illustration, on right, I made showing that we cycle from the menstrual phase to the follicular, to ovulation, to luteal, back to menstrual over and over and over again. The cycle does not stop. It continues forever from menarche to menopause.

Injuries and how they relate to menstrual cycle. This is the most important to apply when treating the bleeding athletes? Let us look at some research here. In this study, 50 active college females ages 18 to 25 had their grip force tested with a dynamometer during different phases of their menstrual cycle. The study was from 2020. Through the study, it was concluded that grip strength and peak torque were lower during the early-follicular phase than the ovulatory and mid-luteal phase. Some other points from the study that I just thought were super interesting to think about were muscular performance was diminished during the follicular phase. This data indicates that females might be at a greater risk of injury due to decreased strength during the follicular phase than other phases of their cycle.

It also said things like female athletes appear to be at a greater risk for ACL injuries than male athletes. Female basketball players tear their ACL almost three times more than male basketball players. Studies indicate knee joint laxity and menstrual cycle phases are related. Injury rates may fluctuate based on hormonal changes that occur throughout the menstrual cycle. What does this all mean? Well, it basically means that we are realizing in the medical field that the phases of the menstrual cycle affect our musculoskeletal system in more ways than we could have ever imagined. This is super interesting. Even though this might seem like a disadvantage of, it is more likely that my female basketball player patient is more likely than my male, this research puts us at an advantage because now we know. We are aware of when our female athletes are more likely to get injured. We can train them and teach them appropriately, so that we can prevent this or at least try to prevent this.

Let us just talk about the conclusion here for a second, that are grip strength and peak torque were lower during the early-follicular phase than the ovulatory and mid-luteal phase has. Their grip strength was less during the early follicular phase. What phase comes before follicular. It is our menstrual phase. They are saying, they are concluding that right when the patient is done bleeding, right when they lost 10 to 80 milliliters of blood, their grip strength was less than the rest of the phases. That honestly makes perfect sense to me. Like we said, we are losing electrolytes, iron, blood, and fluids for four to seven days. It makes sense that our strength is not where it normally is. Again, telling your athlete that they might not be able to do things that require so much strength during this beginning of their follicular phase and not to be frustrated with is very important and liberating for them. 

Here is another study. This study was from 2018. Basically, serum samples were taken from 26 recreationally active women from one menstrual cycle, so one month, and were analyzed to determine relaxin levels, that is the hormone that we said was the most important for our athletic injuries, throughout the menstrual cycles. The purpose of this study and why they are evaluating relaxin levels is because they are thinking that ACL injuries have a correlation to this relaxin hormone. A lot of the research, if you look it up and if you type in Google Scholar ACL injuries and relaxin, there are so many. It has been concluded that increased relaxin levels increase ligamentous laxity everywhere in the body, not just in the pelvic ligaments. Therefore, it can lead to more injury in our athletes. This study concluded that there is a significant change in relaxin levels throughout the menstrual cycle. We know this. Our hormones rise and fall. As we go through, you will see their days are not exactly perfectly matched up, but this study concludes that relaxin peaks occur on average luteal day 9 or 10, so about three days after peak progesterone. You are probably mid-luteal phase during this time. We know our luteal phase is approximately, in a normal cycle, 14 days.

Here is another study. This is from 2017. This is examining the effects of the menstrual cycle on lower limb-biomechanics, neuromuscular control, and ACL injury risks. This was a systematic review. Multiple scientific databases were evaluated to investigate the effects of the menstrual cycle on lower limb-biomechanics, neuromuscular control, and ACL injury risk. Very similar to the other one. It was concluded by this study that females are at a greater risk of ACL injury during the pre-ovulation phase of the menstrual cycle through a combination of greater ACL laxity, greater knee valgus, and greater tibial external rotation during functional activity. This study says that ACL injury risk is greater right before they ovulate, so right before that FSH and LH peak. The previous study said it was mid to the end of our luteal phase. What is the deal with that?

Well, there was another study done. This is about contraceptives. We will do this and then we will come back to the other study. This one evaluates how oral contraceptives or the birth control pill affects relaxin-2 levels in elite female athletes. Basically, it was concluded that your female athletes that do take oral contraceptives have lower relax in-2 levels, which makes sense because they are not cycling.

This study is about ACL and our cycle phases. This one was from 2017, Effects of the Menstrual Cycle. Searches were conducted across multiple databases to evaluate the effect of the menstrual cycle and contraceptives on ACL injury and laxity. This, again, is regarding oral contraceptives. There is an association between hormonal fluctuations and ACL injuries. We know this in the previous research. Oral contraceptives may offer a 20% more risk reduction of ligamentous injury. Literature suggest that ACL laxity and risk of injury may be increased in the ovulatory phase.

When we are talking about fascia, which is relaxin and fascia are really the two things that were worried about when it comes to your athlete getting injured during different phases of their menstrual cycle. Dr. Carla Stecco, I watched one of her lectures and the research that she showed during that lecture. If you never watched any of her lectures, I highly recommend it. She concluded and she lectured that fascia is influenced by sex hormones, specifically estrogen. Fascia is much more active in the periovulatory phase compared to the follicular phase, and is the most active in pregnancy. This is because of collagen type III. Collagen type III is motor adaptable more in pregnancy and periovulatory than follicular phases and even less postmenopausal.

After we ovulate, it is saying that the fascia in the body of the athlete and of our bleeding patients is more elastic. It is not holding things together as good as it does in other phases of the cycle. This can lead to an increase of joint instability, which is very important to know. In the study that she showed, they actually researched and found that foot length is increased in ovulation compared to menstruation because of the greater elasticity of the fascia. Ovulation presents less of balance compared to menstruation. What happens is because the fascia is more elastic and can stretch and is not holding things together as well, the foot can lengthen. Because it is not holding things together like a tight bundle. The foot size will increase. Because of this, the plantar fascia is more mobile during ovulation. The balance of your athlete will be worse during ovulation than it is at its polar opposite of menstruation, which is very, interesting to know. This is the study that she showed showing the foot size.

I want to go back to our questionable contradicting studies here. We know that this said that our relaxin peak on average during luteal phases 9 or 10, so mid to end luteal phase. This one says that the risk of ACL is greater before ovulation. What does this mean? Everybody is different and hormones are influenced by, as we know, stress and other factors. I would say during this study, we know that the risk of ACL injury is more during when we are just looking at relaxin. Relaxin is the highest from right before we ovulate until mid-luteal phase. That is a pretty big gap where we know relaxin is the highest. However, take this Carla Stecco stuff into account, this study, and we know that the middle of that point, so the mid between pre-ovulation and mid-luteal, there is the ovulation where your fascia is less stable. It is not holding things together as well. Therefore, it causes joint instability. Yes, your athlete is at a higher risk of injury during pre-ovulation to mid to end of luteal phase. At ovulation, you have those high levels of relaxin as well as those high levels of type III collagen. Therefore, the joint is most likely the most instable it will be at their ovulation. Your athlete is more likely to get injured during that span of time, then during any other phase of their cycle.

We just looked at some research. Some of the research included studies done on contraceptives and how the using contraceptives can reduce the risk of athletic injury by about 20%. I always like to educate my patients on the different contraceptives. I never recommend a patient to go on a contraceptive because when you are on a contraceptive, your body is not cycling normally. Therefore, your tissues of your body, your mood, your libido, nothing is in homeostasis. A bleeding person has a right to choose what they do with their body, so I like to unbiasedly educate them on contraceptives, the different options, and also the benefits and risks that can come from using a contraceptive.

There are multiple types of contraceptives. There are oral contraceptives, which we talked about the most in this lecture, which is the birth control pills. There are IUDs, which there is copper or hormonal. They are little like T-shaped inserts that go into the cervix and open. The hormonal obviously releases hormones at a monthly increment. There is the birth control implant. It is normally put in the arm. They cut a little insert. They put it in, and again, it releases hormones in a monthly increment. There is the injection. There is a patch. There is a vaginal ring. There are many options for contraceptives that your athlete may be on. I suggest looking at the risks of each specifically just so you know. Maybe if your athlete has other things going on, it could be related. There is no menstrual cycle if a patient is utilizing hormonal contraceptives. If your athlete is using hormonal contraceptives, this entire lecture does not apply to them at all. Their body is at a baseline, thinking they are pregnant every day of every single month. It is completely different.

A study was performed on a sample size of over 1,000,000 bleeding people that concluded that women who were taking oral contraceptives were more likely to also be prescribed an antidepressant. These are just some overall contraceptives facts that are scientifically proven that I like to share with my patients when they are considering contraceptives. There is a 300% increased risk of developing Crohn’s disease while taking oral contraceptives. Oral contraceptives have been linked to autoimmune and thyroid disorders. Oral contraceptives cause delayed B12 and magnesium deficiencies. If you have an athlete and they are taking contraceptives, you need to make sure they are supplementing these, especially if it is an athlete because they need these things to perform optimally. Contraceptives have also been linked to an increase of blood clots, cervical cancer, breast cancer, and liver cancer.

I highly recommend the book Beyond the Pill by Dr. Jolene Brighten. I have read it countless times and I also recommend it to pretty much all of my patients interested in cyclic living, have been on oral contraceptives or any contraceptives, as well as thinking about it because it breaks down exactly what happens in your body when you go on a contraceptive. It allows for more insight and knowledge of what is good and what is bad about them.

This is something that I talk about a lot with my patients. I am not going to talk about it heavily here, but I do think it is important to mention because it does not get enough credit. Again, Dr. Jolene Brighten, in her book Beyond the Pill, goes into this a lot. Like what happened to me that I explained in the beginning, when you have an irregular period, so you are put on the pill. When you decide to come off the pill, everything gets worse. This is what post-birth control syndrome is. Basically, birth control shuts down the communication between the brain and the ovaries. It can lead to so many symptoms. I am just going to use the general thing of irregular menstruation painful period and stuff like that. Everything is worse than before.

I have had the most success treating this in my patients by using acupuncture, referring to an acupuncturist that I trust, Chinese medicines or herbs, making sure they have quality supplementation. Birth control, especially oral contraceptives, deplete the body of folate, B12, and magnesium. You want to make sure that they are getting good quality supplements for that in order to make up for lost time of nutrients. It is important that they are getting a sufficient diet because you can supplement all you want, but you need nutrients from food as well.

How can we teach our athlete to know what phase she is in? How can we start to get her in touch with her cycle, training with her cycle, and knowing where she is at and how to do things? There are three things that I suggest with my patient. Number one is I teach all my female patients about their cervical mucus, how it changes throughout their cycle, and how you can use that to gauge what phase they are in. Basal body temperature is extremely helpful, extremely accurate, but also can be extremely annoying. We will talk about it. Three, journaling.

Let us start with cervical mucus. Cervical mucus is the discharge that you will see in your underwear. If you pick it up in your fingers or you can even see with your eyes, it has different consistencies. This is because of the hormonal fluctuations throughout your cycle. During your bleed, the cervical mucus is blood, tissue, fluid, stuff like that. In follicular phase, it is normally watery and thin. During ovulation, it is sticky and egg white. Ovulation is this one. This is known as your fertile mucus. This is when you know you can have a baby if you try. If you put it between your fingers and you spread it apart and it stays together, just like in this picture here, that is your fertile mucus. That is how you know you are ovulating. During your luteal phase, it will be thick, creamy, and white.

Option number two is teaching your athlete how to take their basal body temperature. I recommend doing this to start. You do not have to do it forever, but it scientifically shows where you are in your cycle based on your temperature. It is super accurate, and that starts to allow the athlete to understand the rhythms because they can see exactly where they are at. Then, they can transition off basal body temperature and more towards the mucus and journaling because they start thinking, “During this phase, I feel like this and my mucus looks normal,” remember it is person dependent. What basal body temperature is it is taking your temperature during the hours of 4:00 and 7:00 a.m. every single day at the exact same time.

If you wake up at six, walk around your house, drink coffee, eat food, and then you take your temperature, that is not your basal body temperature. Their alarm goes off, they open one eye, they grab their thermometer and they put it under their tongue. It is when they are fully at rest before they  have done anything. This is your basal body temperature.

I always recommend the app Premom because I like the way the chart looks. You enter the temperature from the thermometer into the app and it charts it. You can see what your temperature is doing in the phases of your cycles. We know that during your follicular phase, your temperature is pretty consistent here. Right before you are about to ovulate, your temperature will drop then it will spike way higher than any other temperature in your follicular phase, stay up, drop again. When that drop happens, that is your progesterone dropping, and you will get your period. Teaching your athlete how to do that for a few months might start getting them in touch with the different phases of their cycle.

While they are doing basal body temperature or even if they are not, I think journaling is very important. This is the first homework assignment I give all my patients who are interested in cyclical living. They get a journal dedicated to justice.

Every day, they write the date, day of their cycle, their mood, energy, and their emotions. Over time, they will start to find patterns.

For example, day 7 is a weird day for your athlete and if they look back in their journal, it is more than likely that day 7 on every single month is also weird. They start to know how to treat their body during those days.

On day 6, they might start to think, “Tomorrow is day 7. I know I am going to be tied and it will not be a good day for me. I am going to start my day off with a workout that aligns with my cycle to get my mood better.” They become aware of their cycles and how that makes them feel.

I find that athletes really like this because they like keeping track of their performance. They like being aware of their body. Journaling is a nice homework assignment for them and they tend to like it and be really, persistent with it.

Those are how you teach your patients how to track their cycle. Those are some of the general ideas. We went through a lot, but here is the big picture of everything we learned today. We now know that bleeding bodies change weekly because of our hormonal fluctuations. It affects our mood, our libido, our concentration, everything. Our cervical mucus, the way we should exercise, everything changes weekly because of our hormones. That is normal. In order to optimize female athlete performance, we need to educate her to train with her cycle.

During bleed phase, we instruct her to rest. We know athletes will not, so tell her to take it a little bit easier. Give her permission, maybe day 1 and 2, to rest, do nothing, gentle stretch, gentle walk. Follicular phase, tell your athlete to focus on their flexibility. Ovulation, they need to do more cardio. During your luteal phase, make sure they do some weight-bearing exercises to support that decrease in estrogen.

Bleeding athletes, we saw through research, are more prone to different injuries during different cycle phases because of our relaxin levels and because of the changes in fascia stability. Her strength will be decreased and muscular performance will be lessened during the early-follicular phase right when they are done bleeding, and then it should rise again. Her ligaments will be the most lax during ovulation and the beginning of luteal phase through research. We know that our fascia is the most instable at ovulation. That is the point to look out for. Make sure you are doing stabilizing exercises with your athlete during this time. Make sure they are not doing any crazy lateral motions during this time to protect their ACLs. This is the time to stabilize the joint and be aware of the biomechanics of your athlete.

Here are other athlete-related ideas regarding the menstrual cycle to be aware of. It is seen in specific sports, like dance and gymnastics, that amenorrhea is a trend. Amenorrhea and osteoporosis go hand in hand here. If your athlete is not getting their period or their bone density is just not where it should be for their age, I recommend sending them for some help because it normally is related to an eating disorder of some sort, whether it is anorexia or bulimia. If they are not getting their period, ask the mental health questions. If they do disclose that they are having trouble with eating, recommend a counselor that you trust. Maybe find or make some connections with a sport psychiatrist in your area that you trust that you can recommend to your athletes that are experiencing this thing.

Dysmenorrhea, this is just irregular menstruation is the broad term of dysmenorrhea. Where amenorrhea is you do not get your period at all. Thirty-three percent of athletes with the BMI lower than 25 present with dysmenorrhea. Your body needs a certain percent fat to have a baby, which is why we have a menstrual cycle. Even though if your athlete does not want to get pregnant, that is fine. They still need a certain amount of body fat of body mass to have healthy hormonal fluctuations.

Painful periods from overwork as well as back pain during their periods. My patients love to come see me when they have their period because their back is sore. I am a chiropractor, so I do some soft tissue heat. Making sure that they are having hot teas and hot foods at home when they have their period. Being aware that maybe if you can adjust their lower back, do some soft tissue work, put a hot pack on their lower back and their sacrum can be really beneficial for cramps and back pain that our bleed related.

Teaching bleeding people to live in tune with their bodies is such a potent gift and I have seen life changing results in my patients from being able to empower them and give them the gift of learning of what their body is supposed to do and how they are supposed to train.

If you have any questions regarding anything in this lecture or anything else, feel free to send me an email. I look forward to the future of our cycling athletes in all that you are going to teach your patients and how empowered our female athletes are going to feel after this. It has been an absolute pleasure teaching you today. Thank you

Email: trovemenstrualhealth@gmail.com.

 

[End]

English Direct Download PDF ICSC09 _Section 6_Regional Diversity

ICSC Culture Diversity Module 09
ICSC09 _Section 6_Regional Diversity
Instructor: Steven Smilkstein
Video Lesson: 01:20:58

Welcome to the ICSC Cultural Diversity Module. The FICS Education Commission, has started building up new material, covering sports, cultural, and religious diversity to expand further into our sports knowledge and application.

Sports has been a constant tie-in between nations, cultures, and groups. We have managed to break those boundaries and move all our information not only into looking at different groups in the world, but what similarities we have.

What we came up with was that there are 9 main regions that FICS has been predominantly involved in. We have split those 9 regions and identified the top 10 sports in each region.

From there we have reviewed the top 3 sports per region in the following categories:

1. What injuries are happening around those top 3 sports.
2. The similarities between sports and regions they are commonly popular in.
3. Which sports are commonly found across regions.
4. Looking at the Worldwide Sports Federation and the most popular sports across the 9 regions.

The 9 regions that identified are:

1. Latin America,
2. Asia,
3. Middle East,
4. Europe,
5. Scandinavia,
6. United States of America,
7. Canada,
8. Australia,
9. South Africa.

This module is to present the top-rated sports per region, to highlight the similarities, diversity, and links between the different regions. It educates us as Sports Chiropractors to be able to work across regions, adapt to diversity, unify our approaches and accommodate any sport on any playing field.

Our passion as Sports Chiropractors, is sport and our belief is to give sports athletes the best advantage by boosting their performance, by understanding their biomechanics and addressing their needs in the sport that they are participating in. This is achieved by learning and understanding the sports around the world.

The following regions have these specific top sports that we are going to look at and break down the collected information to look at the most common sports out of each of those regions. Further we can look at the common injuries that occur in those sports.

Region 1: Latin America:

Football (FIFA) was the top-ranking sport in the region. Football is the most popular sport in the world, it is not uncommon to see it, and we will see it appear in almost all the regions.

Rugby League and Rugby Union; mostly Rugby Union are played in some of the larger countries in South America, Argentina, Paraguay, and Uruguay. There has been a lot of conferencing across the world when it comes to Rugby. Argentina is a high-ranking nation in the IRB standings especially in the Rugby World Cup.

Golf is the third most popular sport due to the good weather and southern hemisphere climates.

Tennis, basketball, volleyball, baseball, and motorsports such as Rally, Formula 1, and MotoGP are very popular in the Latin American regions. There is quite a famous rally race around the country of Bolivia, due to the extreme altitudes and tough terrains.

Beach Volleyball is quite prominent in international competition especially in Colombia, Brazil, Panama, and Chile.

Surfing is a popular beach sport which is prominent around the Brazilian coastline.

The common injuries found in the top 3 sports in the Latin America region.

Football:  A recent study revealed that lower extremity injuries were involved in 84% of the cases that were documented in high level football players. 66% of those lower extremity injuries were traumatic-based injuries, due to from tackles, from falls and, or from bumps. There is a 34%  occurrence of overuse injuries which are non-traumatic in nature. These occur due to training many hours with a high turnover of match time due to more than 1 league occurring at the same time.

Research was done in the 1980s where it calculated the average distances that football or soccer players had covered during match time. The average soccer player in a 90-minute match runs up to 15 Kilometres. It is a large distance considering a 100-meter-long sports field that they are running over 150 times.

• Ankle sprains were the most common out of those lower limb injuries.
• The contact injuries were mostly from tackling and challenges.
• More than half of the 20% of knee injuries were caused by tackling.
• Players participating at Premier league levels had only 30% of injuries during tackling and 54% more in the running phase.

Rugby Union: Due to the physical nature of the game and the contact tackling in Rugby, Traumatic injury commonly occurs.  Thigh hematomas were the most common injury for forwards and backs in the sport itself. Rugby is a tactical sport where the players in the 15-man team is assembled in two packs working together on the field, the packs are divided into; 8 forwards numbered 1 to 8 and 7 Backliners numbered 9 to 15.

Very similar to American football NFL, where we have your offensive and defensive teams, excepting that all 15 players are on the field throughout the game of play, and there is no break between plays, it does increase the pace and increases risk for injury.

ACL injuries are more common in forwards injuries in forwards. Ankle injuries affected backs more than forwards. The contact mechanisms accounted for 72% of injuries. Foul play was only implicated in about 6% of those injuries. The ruck and maul elements of the game are the most common points of injury to the forwards. Being tackled caused the most injuries to the backs.

Due to the high-impact nature of the sport, head and neck injuries, though not common via active prevention measures, and strict refereeing techniques and the control measures, do still occur.

Rugby has implemented what we call the White Flag or the White card component which allows a player to be taken off the field quickly and assessed for any concussion and or head and neck injury. This is activated if the referee deems that there is a potential head or neck injury, they pull out a white card, play is stopped to remove that player, allow the player to be assessed but still continues with play once the player is removed off the field. If the player is cleared, they are allowed to come back onto the field and return to play. If they are not, there is an immediate substitution which is allowed without losing that substitution.

Golf: Most golf injuries, whether it is pro or amateur level. Overuse injuries are due to excessive time spent in golfing and practicing swing and improvement in technical deficiencies.

Repetitive motion injuries that do happen tend to affect the golfers over time and may be post event on presentation.

The two main causes among golfers have their specific differences, but the pattern in which they occur in professional and amateur golfers do tend to differ, but the results do end up being the same.

We do see more overuse, and traumatic origin injuries in an amateur golfer who hits the ground with their club this is a high resistance impact with a force follow through from torsional forces in the spine, hips and shoulder. This mechanism causes a lot of vertebral impingement or even synovitis in most of the joints undergoing torsion. This can result in disc based injuries.

In the amateur golfers, the elbow is the primary affected region or joint.

There are more cases recorded of tennis elbow than golfer’s elbow. Yes, the names differ across each other, but the tennis elbow mechanism, especially on the lead arm, does cause lateral epicondylitis. For most golfers.

If performing a right-handed golf swing, and if there is contact with the ground instead of hitting through the ball, the lateral epicondyle takes more strain and that causes more of a tennis elbow epicondylitis. Whereas on the back hand, if there is more force coming through there, we might see the medial epicondyle taking strain.

We do see thoracolumbar-based problems, because of that rotation of the trunk and the torso, especially in the golf swing. If there are any insufficiencies, we do see that they are more core muscle strength-based and do affect the ability of play for each player.

Region 2: Asia:

Football: Football Association (FIFA), was the most popular sport across Asia.

Cricket: Due to the high population numbers in the sub-continent, contributed to cricket being ranked as the second most popular sport in the Asian region.

Baseball is the 3^rd most popular sport, especially in Japan. There is quite a lot of crossover sports that have come across the regions, and we find that Japan and China have embraced baseball.

Other sports which are quite prominent in the Asian region are; Table tennis, Basketball. Basketball being popular in the Russian Federation. Gymnastics which is popular especially for the Russian IOC (ROC), and the Chinese sporting groups. Athletics and IOC based sports, mostly in Russia and China,

Competitive martial arts such as Judo, Karate, Taekwondo, Kickboxing, and Mui Thai. Those have really grown worldwide. The focus being around Thailand and the Thai cultures. A lot of Thai-based sports such as Mui Thai, have really grown quite a lot and developed popularity in competitive platforms.

Field Hockey in India and sub-continent that one of the top ranked teams in most of the hockey-based competitions.

Precision Sports, such as archery, do tend to be competed, especially Taipei. Chinese Taipei and Singapore does have a big following. China and India also have strong groups in this sport.

With football, the information provided is based on world stats. We will see quite a lot of repetition of information with regards to football.

Cricket is quite a fun sport to watch in quite high intensity, especially that it has grown quite vastly, especially in the Indian Premier League or IPL.

There is a lot more cricket being played, so we are beginning to see a lot more injuries. Acute injuries are the most common form of injury in the sport, especially contact injuries from either the ball hitting the batsman from bowling, or the batsman hitting the ball into a fielder.

We have seen quite a lot of traumatic injuries locally in South Africa. There was a famous case, that of best wicket keepers, Mark Boucher. He suffered a bad injury, where the ball hit the stumps and the bails, (the little wooden pieces that sit on top of the stumps) dislodged and impaled him in the eye. It caused permanent eye damage for him and forced him into retirement form the sport.

Overuse injury is also common, with hamstring strain as the most common form of injury.  Cramping is quite a common issue, especially in the longer formats of cricket such as unlimited overs cricket.

There are 3 formats.  The first format is our shortest format being T20 Cricket, which is 20 over Cricket. In each innings, the batting team faces 20 overs in their innings, and they need to score as many runs as possible in those 20 overs, or their allotted wickets, which are 10 wickets. The Bowling team aims to get the batting team out as soon as possible and prevent as many runs from being scored as possible. The only way of getting a wicket is by bowling the ball into the stumps (Wickets) or their legs before the stumps, catches the ball in the air or runs the batsman out, when they are outside of their Crease (safe zone).

The second form is the most popular and the most mainstream format of the game is the One Day International or ODI Cricket. This is 50 overs-based Cricket where the innings are 50 overs each.

We do tend to see higher scores but it is a lot more strenuous on the body where the batsmen are out there for at least one and half to three hours depending on the pace of play.

Then you have the 5-day Cricket, which is unlimited overs. There is no limitation in the overs bowled in the innings, but the game is extended over 5 days. Each team gets 2 innings to score as many runs as possible in the 5-day game. Every single batsman has the potential to stand at the crease for multiple days of play, which means that dehydration is a big factor and a lot of strain on the player, and high enough electrolytes, fluids, and nutrition being utilized throughout their batting time. With this prolonged batting time, there is repetition of movements and strain.

Each bowler has the chance of 6 attempts to bowl the ball which is called an Over. In international cricket, in ODI, the bowlers will have a maximum of 8 overs, and in the longer format: unlimited overs, the bowlers are not limited to the number of overs they bowl. This means that some bowlers can bowl up to 20 or even 30 overs. You now consider that they are running up to 180 times down the pitch. This results in a lot of strain if there is a lot of force, especially when they are launching the ball in the bowling action, and that can cause a lot of stress fractures. We do see it in a lot of the younger groups, 19 to 20-year-olds, who are high-performance junior players. They start suffering with a lot of these stress fractures or hot spots, lumber stress fractures that do come up later in their careers.

Concussion is something that does happen, especially when they have been hit by a ball. There was a famous case only a few years ago where there was a famous Australian batsman that got hit on the back of the head and unfortunately passed away due to severe head damage. More safety improvements have been practiced where they have created more shielding on the helmets themselves, but it does add risk and cause more discomfort for the batsman, more heat under the helmet, more temperature management issues, and more risk for dehydration.

Baseball: Baseball is quite an interesting sport because there is the impact factor but also repetitive motion factor, especially for pitchers, there is a lot of repetitive strain.  Rotator cuff and ligamentous capsule injuries are very common, this results commonly in shoulder dislocation, and a lot of biomechanical lesions, such as SLAP lesions, biceps tears, and shoulder instability. Pitchers also develop hip and groin injuries because of the motion used in the wind up and launching the ball. The batsman does suffer traumatic injuries when hit by the ball and when they are running between bases, the base plates themselves are protrude from the ground which causes traumatic injury to fingers, toes, feet, ankles. Commonly Mallet finger is caused when the batter has slid into the plate, and unfortunately the plate has contacted them and dislocated the distal interphalangeal joint causing a lot of damage. There have been a couple of times where an ankle has sprained, especially stepping onto the plate on the edge where the ankle slips causing a lateral ligament (ATFL, CFL or PTFL) sprain or even a full subluxation, or fracture.

Region 3: Middle East

FIFA football is the most popular sport in the Middle East. It is the world’s most popular sport, and it is followed quite strongly in the UAE, in Israel, and in Lebanon.

Cricket is the second most popular in the region but is prominent in the Saudi Arabian region and in the United Arab Emirates. Cricket is played in the United Arab Emirates (UAE) which is a host to Pakistan and Bangladesh. Pakistan now is using the United Arab Emirates as their neutral field because of political issues, monitored by the International Cricket Commission or ICC.

Horse Racing is the third most popular sport in the Middle East region. Most equine sports such as horse riding, do tend to feature in the UAE.

Another sport that does feature is tennis un the UAE. There was quite a famous friendly match that happened between Roger Federer and Rafael Nadal, where they played on the helipad on the Burj Al Arab. It was recorded as the highest altitude game of tennis ever played.

Other sports that are featured in the middle east are: Motorsports: Lebanon as one of the frontrunners in the A1 GP, which was launched about fifteen years ago. Many middle eastern countries that are famous for hosting the F1 GP Jordan, Bahrain, UAE, and Saudi Arabia do host a lot of the big F1 sports [inaudible]

Camel racing: The middles east has a strong cultural history and being such a big traditional area. Due to this camel racing is still one of the most popular sports.

Golf: Golf has featured a lot in Israel and in the United Arab Emirates. Other places like Turkey do tend to have quite a lot of beautiful golf courses and a lot of local golf competitions.

Basketball has grown in Israel quite a lot, which reaches up in rank number 8.

Rugby has grown again in the UAE, Saudi Arabia, and Israel. Israel hosts an event called the Maccabiah Games, and rugby is one of the main features in the Maccabiah competitions.

Falconry, especially in the UAE and in Saudi Arabia. There is a lot of focus in traditional falconry, which is considered a sport.

We have discussed the injuries and management of Football and Cricket in previous regions.

Horse Riding is quite an interesting sport. This is because of the volatility of the animal and because of the high-risk nature, the unpredictable nature of forces, the height, their weight, and their potential high speeds, equestrian athletes are at risk to head and spinal injuries, and quite severe injuries.

Traumatic brain injuries or TBIs, including concussions, are more common than spinal injuries. Both injury types are most related to a rider falling from a horse. There have been several cases, Just recently in the Olympics, there was a rider who fell from a horse, and the horse ended up trampling on the rider. It is a common thing to happen in the sport, especially in high-speed equestrian pressure riding.

In the dressage and jumping competitions, there is always that high potential for falling off the horse. Spinal injuries are less common but are associated with potentially significant neurological morbidity when spinal cord injuries do occur. Most equestrian-related injuries occur during schooling or non-competitive riding. A large proportion of the injuries involve children and teenagers, with one study finding that 39% of horse-related injuries occurred in patients under the age of 19 years.

Region 4: Europe.

FIFA football is the most popular sport in Europe. After that; Golf, Rugby Union, Boxing, Tennis, Motorsport, Cycling, Field Hockey, Cricket, and Handball all feature as major European sports. Boxing has quite a big following. Handball even though it is a young sport, and especially for the chiropractors who are working in the World Games, it is a main feature sport in the IWGA World Games. It is always an interesting sport to follow and to read up about.

The aim of this module is to expose you to what sports are out there, and also get you to be prepared so that when you go out to these sports events, you have brushed up or you have read up on the sports that you will be working on.

The next portion to this is the common injuries that are found in the top sports in the European region.

Football (FIFA) is the most popular sport in the European region:

As we know the largest football tournaments in the world are based across the European continent. These are; the English Premier League, the UEFA cup, the Euro championship, La Liga, Spanish La Liga, Bundesliga and many more.

It is assumed that some clubs are playing up to 3 matches a week each for a different week. If we had to consider field and play time of approximately is 90 minutes a game, that is 270 minutes of playing time per week, excluding training time. We find that most of these players, if 270 minutes are the playing time, it is a minimum of 514 minutes of training time excluding the matches. This has increased the incidence of overuse injuries in European football, but again we still see a lot of those traumatic injuries in high paced tackles or hard challenges. The rules have, limited injuries, but again the level of refereeing has also a big role to play in prevention of dangerous tackles or play.

Golf is the second most played sport across Europe. There is a short period for the European tour, There are a lot of open tournaments that do happen around Europe, especially with high intensity games where we find that in the Ryder Cup or the Presidents Cup (Which each happen every alternate year).

This results in a golf being played where a lot of the players are playing up to 72 holes a day over a 4 day period, so it is a lot of pressure on the players, and they take a lot of the strain.

Fitness levels do have a big role to play with these players, and a lot of the professionals do tend to manage what they can and cannot do. You will see players often pull out of a tournament or “not make the cut” due to fatigue or drop in performance.

On a professional basis, these players are not allowed to use golf carts. On an amateur basis, golf carts are used, but again in certain competitions, it can be frowned upon.

Rugby is the third most played sport in Europe. Most statistics have come from Europe, South Africa, Australia, New Zealand, and from Latin America. But, we do find that the information has been put into one big mix, and a lot of the Southern Hemisphere players are crossing borders and playing in Europe during their ‘off season’. We are finding a lot of South Africans, Australians, and New Zealanders playing in a lot of the French Leagues or even in the British Heineken Cup. There is a lot of cross-over where these players are going around, playing for clubs in Europe outside of their home season, and having full year seasons instead of the old winter season only, and no longer resting throughout the summer months.

Region 5: Scandinavia

We find that, FIFA football is the most popular sport in this region.

Then comes an interesting sport, being floorball, which is a static version of roller or ice hockey, but instead of using rollerblades or ice skates, they are using normal footwear, and they are running a wooden floor court. Equestrian sports are also quite popular in the region. Handball, Golf, Gymnastics, Athletics, Ice Hockey, Winter Sports such as Skiing, Bobsled, Cross Country, and Curling, amongst others, and then also Korfball. Korfball being a very interesting sport, very similar to Netball, but there are certain differences where you have an attacking team and a defending team, and being a mixed sport, it opens a lot of interest into these cultural diversity changes where there is no gender effect in the sport itself.

The common injuries found in the top sports in Scandinavia:

We are looking at football where the lower extremity was involved in 84% synonymous to the worldwide statistics based on traumatic and overuse injuries, during normal routine play and practice along with foul play.

Floorball. We find that there are overuse injuries that were more common among the men and were primarily back problems. The thigh was the most common injury location in male players, and the ankle in female players. We found that the traumatic injuries were more common in women, and mainly knee and ankle injuries were noted in those injuries. The incidence was significantly greater in female floorball players throughout the entire floorball year. Male players sustained mostly overuse injuries while female players suffered traumatic injuries. Most injuries in floorball were mild irrespective of player gender.

Equestrian sports in Scandinavia were the third most popular.

Injuries in this sporting type is due to the unpredictable nature of horses and the intensity the type of riding. We see a lot of fall and trample injuries that result in severe injury especially spinal, and traumatic brain injury (TBI). Most of these injuries occur during practice and training rides more than competition.

 Most of our injuries do occur in younger riders due to the inexperience and control issues of the animal. But we cannot overlook that in high performance competition, that riders do not fall off their horses and get hurt.

Region 6: United States of America.

Collecting sporting information from the USA is amazing. It is a unique sporting culture and especially because it has created its own sports. We see a big difference in the USA compared to many other regions. American football or NFL based football is the most popular sport in America, followed by baseball or Major League Baseball (MLB), and basketball, which is the National Basketball Association (NBA), and then ice hockey, soccer or major league soccer (MLS) in the US, tennis, golf, wrestling in the form of both Olympic wrestling, grapple or sports entertainment wrestling, rugby, and then motorsport.

The culture in the USA focuses mostly on high performance. Even in entertainment wrestling, there are still high risk manoeuvres or high injury manoeuvres that do occur. I was very privileged back in the day when WWE wrestlers came to South Africa to visit here in Johannesburg. I got to meet some of the big guys that all of us saw as big heroes, guys like Rikishi, Brett Hart, Triple H, Ray Mysterio and many more. These athletes who were rather large individuals and watched them move around a small ring. Their bodies took a lot of damage due to falls, collisions and blows. These guys all suffered from knee problems, hip problems, thigh problems, and we got to work with them with a lot of the sports chiropractors in South Africa.

 NFL American football as the most popular sport across the USA region has a long list of injuries.

We see the knee injuries in the sport. It is a high contact sport. It is a high paced sport, and it is large amounts of forces in tackles where guys are throwing full bodies into the tackles themselves, and again, a lot of extension where there is open chain or even coming down into a closed chain in an attack. There is protective equipment that is worn by the athletes, but due to the forces and stress from full force tackles, we still see severe injury to players. Commonly ACL injuries, PCL and MCL injuries, are most common being the ACL tear in the knee. Head injuries are prevalent where the NFL is recorded as the highest concussion in world sports. There is a high incidence of head injuries due to helmet use, but also helmet use has reduced the severity of concussion, so there is quite a big conflict in the concussion discussions where injuries have happened because of guys throwing their whole bodies into a tackle, compressing their heads against a hardened helmet and causing contusions or contra-coup lesions.

The concussion research that we have seen is from the NFL, and again, this has opened up a whole new chapter of looking at post-concussive syndrome and the best management of concussion.

Upper limb injuries do happen, especially the shoulders, hands, and digital injuries, especially in receivers, especially guys who are jumping and getting tackled landing on their shoulders landing on their arms, commonly called FOOSH injuries or fall onto outstretched hand injuries. This does tend to  result in a lot of strain, fracture or dislocations in multiple different sites.

Major League Baseball is the second most popular sport.

There are a lot of rotator cuff and ligamentous capsule injuries. These injuries involve the hip and groin. Traumatic finger and foot injuries also occur, such as Mallet finger, avulsions, due to impact on the plates, causing a lot of those dislocation, subluxations, and a lot of traumatic joint injury.

Basketball is the third most popular sport.

It does tend to have some injuries, but there not a massively high rate of it, so they do tend to have a lot more game-related injuries compared to practice-related injuries. We do see ankle sprains more than anything else, followed by patellofemoral inflammation, which is the most significant problem in terms of days lost in competition. It is not the most common injury, but it does have a big effect on game time or loss of game time.

We do see hip and groin injuries especially when they are considered in a lot of court hours in training where they must perform court sprints, or run, and we do find that there is a lot of avulsions especially in the adductor region because of their wide base twist and turning. Again, true ligamentous injuries of the knee were surprisingly rare.

Region 7: Canada

What we do find is that in the Canadian region, we have got different kinds of sports that are presented as popular sports.

It is presumed that due to the Isolation and unique weather systems in Canada, and also that there is a little bit of crossover and influence from the USA that the sports have adopted their own unique versions of common sports.

We are looking at the 3 common sports where Canada is predominantly strong.

We do see ice hockey as the first-choice sport.

Ice hockey is a high impact sport. It is on an unstable surface, and again, high velocity both in players and in puck velocities. The puck being the little disc that they play with on the ice. We do see a lot of trauma that happens in ice hockey. Most people who I have spoken to, especially Canadian guys, say that I think it is the trauma and the violence that makes it such a popular sport. But again, it is quite a skill-based sport and there is a lot of training behind it. The injuries are related to direct trauma. We see 80% of those cases there. Then there is also overuse on a 20% case scale.

Due to high puck velocities, aggressive stick use, and body checking or collisions, they are the reason why we see a lot of these traumatic injuries. The participant can anticipate an injury from playing 7 to 100 hours of hockey depending on their age. Most injuries are caused during the actual game rather than during the practice. Although facial injuries are common, they are decreasing because of adequate use of helmets, masks. Conversely, cervical spine injuries are actually increasing because now with helmets and masks, we are seeing a lot more impact blows to the head. Injuries to the upper extremity include acromioclavicular joint dislocations, clavicle fractures, scaphoid fractures, and gamekeeper’s thumb due to their thumbs constantly gripping the stick and the torsion form the forces of stick impact and slap shots. The risk of the thumb getting caught can cause dislocation at the carpometacarpal joints or the interphalangeal joint in the thumb itself, most commonly the CMC joint, which is the most important restraining joint of the thumb. We do see injuries to the lower limb predominantly which involves soft tissue with strains of the hip adductor, tears of the medial collateral ligament of the knee especially in a lot of the fouls that do happen, and then contusions of the thigh, which are quite common.

Lacrosse is the second most popular sport, and is a very interesting sport that was developed from a combination of common sports into one.

We see links between hockey and football, but comes into quite a high impact, high contact sport, which is quite popular in the world games, and quite a fun sport to watch. Lacrosse does pose problems when it comes to injury management. There is also Canadian football, baseball, cricket, soccer, rugby, and then the winter sports, especially in the Winter Olympics, where Canada does hold a strong ranking amongst the winter Olympics countries.

In Lacrosse, we find that the primary injury mechanism was by contact either with another player or stick or a ball. In women, body-to-body and stick-to-body are the most common injury mechanisms, followed by no contact at all during those injuries. Most injuries noted were contusions, rib and chest injuries and shoulder injuries due to body checking, elbowing, getting hit by a stick, getting hit by the ball. It is again a very intense sport and again adopts from its 2 kinds of root sports that actually has adopted quite a physical game of play.

Canadian football is very similar to the NFL. The stats are very similar to NFL. The difference is just the leagues and the regularity of play in Canada compared to what it is in American football. I have not seen a lot of research on specific Canadian football to compare the statistics on scale to NFL in the USA.

Cycling. Canada hosts the largest endurance mountain bike challenge known as the BC or British Columbia bike race. It starts and finishes in Vancouver, covering the whole of British Columbia territory over 3 weeks of racing. With the country having access to some of the Great Lakes and especially in the summer seasons, there are a lot of water sports that are pursued followed a lot.

Region 8: Australia

The next region that we talked about is Australia. Now, Australia has a  different proportion of sports, but in the same categories as most of the regions.

The one difference is that Australia has its most popular sport in Swimming. Because of the constant fair to hot weather, and most cities are located close to the coastlines, and municipality has good recreational sporting infrastructures. It does lend to most of the Australian population doing swimming and aquatics on a regular basis.

Australia is rated the greatest Olympic achieving nation in aquatics. Excepting swimmers such as Michael Phelps, Fans witnessed great Australian swimmers such as, Shane Gould, Ian Thorpe, Grant Hackett, Ariarne Titmus, Kaylee McKeown and Stephanie Rice to name a few. I think, at the Olympics, there have been more Australian competitors in swimming than other nations in the world.

Rugby is the second most popular sport in Australia.

Falling into the SANZAR group, (South African, New Zealand, and Australia rugby unions). It has quite a strong holding when it comes to its establishment of rugby. Australia has won 2 World Cups in the RWC Competition.

Soccer is the third most popular sport in Australia its team is known as the Socceroos. They have climbed the rankings in soccer, in FIFA based football, and have crossed over into the northern hemisphere where a lot of players do tend to play in European leagues.

Dancing is a very important sport in Australia, followed by basketball.

In Australian football, “Aussie rules”, this is a format of football that is completely different to rugby, but it has taken some concepts of rugby, and been placed on a cricket oval, changed some of the rules where you are able to pass forward by punching a ball or kicking a ball forward, and there are different objects of the game. Also, scoring is kicking based, but not really the same scoring based on traditional rugby scoring.

Tennis. Australia hosts one of the biggest tennis tournaments such as the Australian open.

There is cricket. Surprisingly, Australia has been ranked one of the top cricket playing nations with an influential contribution to sports in both ICC and Test cricket. It hosts a continuous rivalry against England, called “the Ashes series”, which is I think since colonisation. Australia and England have been hosting this Ashes test series every year. Also, in the Indian Premier League, you will see a lot of Australian players moving over to the IPL, especially in their offseason, where IPL is more prominent. There are a lot of Australian players that do tend to take high ranking roles in the IPL itself.

Hockey, as in field hockey. Australia is also high ranking the field hockey rankings, and then Golf.

Swimming:  In swimming, it has been reported that 90% of complaints by swimmers of sufficient magnitude do seek physician’s advice, which pertained to the shoulder.

Problems with the hand and elbow occur less frequently and often can be attributed to other causes instead of swimming. A lot of it might be  due to dry training, or gym-based training, or other sports that they could play a role in etiology.

Epidemiologic studies have reported prevalence of shoulder pain in swimmers ranging from about 3% to 80%. The pain does vary in locations depending on the physique of the swimmer, the length of time that they are swimming, and also the type of stroke that the swimmer is focused on.

It has been estimated that the average collegiate swimmer performs more than 1 million strokes annually with each arm, so there is a lot of overuse-based injuries that do happen around the shoulder joint. It does tend to limit itself sometimes but can limit the progression of the ability to train. It is generally agreed that this repetition or overuse is a major factor in the development of shoulder pain, and that because not all swimmers develop shoulder pain, overuse must be combined with a secondary insult.

These include supraspinatus avascular tendinitis, biceps avascular tendinitis, impingement syndromes, labral damage, instability secondary to ligamentous laxity, and instability secondary to muscle dysfunction. In swimmers, however, we do believe that most shoulder pain is caused by instability stemming from demands that are specific to the sport.

Rugby Union: The crossover between South Africa and New Zealand, Australia, England, British and Irish Rugby Unions, the French Rugby Union, and Argentinian Rugby Unions with smaller groups has created more unified statistics and allowed us to actually focus on worldwide based injuries than just regional statistics.

Soccer football: There is a lot of bleed over where Australians are playing more in the English Premier League and European leagues. But again, in high performance sports, such as soccer World Cup, we do see Australia achieving higher rankings as they compete more.

Region 9: South Africa:

This is, my home region. South Africa is quite a culturally diverse country, and because of that and especially with its history, we found that sports have changed over the years, but there is still quite a big popularity to certain things because of certain population demographics.

Football: Football or FIFA based soccer is still quite a big and popular sport. Yes, South Africa is not one of the stronger nations in international soccer, but the local derbies are quite competitive. It is quite a big local league in South Africa, called the PSL or Provincial Soccer League, and also the MTN8, which is a knockout based top 8 teams. There are a lot of interclub derbies that happen.

Rugby: Rugby, being the second most popular but probably the largest sport in South Africa in the sense that we are the highest ranked in rugby standings and current RWC champions.

Cricket: Cricket is a near third, also ranking quite high in the world, but all my Australian listeners will probably love it that South Africa just cannot manage to do well in the ICC Cricket World Cup.

Running: We do have a high popularity for long distance running in marathons and ultra-marathons. South Africa does host one of the most prestigious ultra-marathons known as the Comrades marathon, where people from across the world come to run in a 89 kilometres long stretch between two towns, Pietermaritzburg and Durban. Pietermaritzburg, being a little bit inland and Durban being a coastal town. They alternate between up and down runs because of the escarpment and the hills. It is one of the most gruelling races and people come from across the world to try and run this ultra-marathon.

Golf: South Africa has got a very big following in golf. Again, we see some big names playing in the European and PGA tours.

Boxing: South Africa has a very big, deep-rooted boxing culture, especially around the poorer communities. Boxing being a highly disciplined sport. We have produced quite a lot of international boxers that are still ranking quite well.

Powerlifting:  South Africa has adopted powerlifting as a mainstream sport, and the IPF has adopted South Africa as one of its most popular countries of representation. We do host the Arnold classics and then in the International World Games Association (IWGA).

In the 2017 World Games, we saw that 4 out of the 12 judges were South African judges in the International Powerlifting Federation. Powerlifting is separate to Olympic lifting where Olympic lifting is quite an interesting sport where you are combining all the 3 main disciplines to achieve an overhead lift of the weights, whereas with powerlifting they separate the 3 different disciplines where it is a squat, a bench press, and a deadlift, and they do a total accumulation of your points.

Triathlon sports: South Africa being a very fair-weather country and very mild winters, we are able to do a lot of triathlon sports. It has become quite a destination country for Iron Man competing. We see a lot of guys like Henry Schoeman coming into the Olympic triathlons and doing a lot of Olympic and sprint events.

Tennis: South Africa, being an outdoor kind of country, because of its good weather, we do tend to have good outdoor sports such as tennis. The Davis Cup has actually been well contested throughout the ’80s and ’90s in South Africa, and then other associated racquet sports such as squash, badminton, and now recently Padel, which has taken the world by storm.

Cycling: Considering that this country is vast and spacious, we do host quite a lot of cycling events. I think the third biggest cycling event is known as the Cape Epic, and is fast growing. A lot of international riders come over to ride in the cape provinces for quite a big bragging rights.

Football and soccer, lends from the international statistics in football injuries.

Rugby Union, same thing, also South Africa being a major contributor to the statistics in the sport. South Africa has won 3 World Cups, with New Zealand, Australia each on  2 World Cups, England has won one. We are seeing a big growth in other countries where World Cup rugby is becoming more and more contentious.

Cricket: South African cricket is high ranking in the worlds. Many South African cricketers have moved into the IPL especially in the South African off-season. But South Africa has had its fair share of ICC World Cup attempts and also a part of the T20 world cup. Just a reminder that 20 over based cricket, which is a much more fast-paced and quicker acting format of cricket, where a lot of more impact-based injuries that are happening in these faster paced versions of the game.

Amongst the nine regions, the following common sports were of most interest. We did see that football, FIFA soccer, rugby union, golf, cricket, Major League Baseball, equestrian sports, floorball, football, basketball, ice hockey, lacrosse and swimming were seen as the biggest crossover sports across the nations. For most of the nine regions, the following common sports were of most interest.

We saw this as FIFA football, rugby union, golf, cricket, baseball, equestrian sports, floorball, football, basketball, ice hockey, lacrosse and swimming.

Coming to conclusions of the sports, we went and we looked at as many researches as possible, looking for those common injuries and those major injuries that happen in these sports.

FIFA Football: In soccer, we took a series of major investigations of soccer injuries, which was done amongst 123 players participating at various competition levels in a Danish soccer club.

The injury incidents during these games is highest at Division level with 18.5 players per 1000 hours and the lowest in that series level of 11.9 per 1000 hours.

Commonly, as explained earlier, the lower extremity was involved in 84% of injuries, of which 34% were overuse injuries. The ankle sprains were most common with 36% of injuries, and equally found in all levels.

Contact injuries during tackling occurred most often in lower series and use, where discipline is still a problem or not at such a strict level.

Players participating at high levels had only 30% of the injuries during tackling and 54% during running, so more than half of the 20% of knee injuries were caused by tackling and most serious injuries presented with a 65% of return-to-play ratio in the same season and a 35% season ending injury.

Rugby Union: Coming through to rugby and rugby union, we found a large-scale epidemiological study of match injuries, which was sustained by professional rugby union players.

To define the incidence, nature, severity, and causes, the method of this was a two-season prospective design that was used to study match injuries associated with 546 rugby union players at all English premiership clubs. Team clinicians reported all match injuries on a weekly basis and provided details of the location diagnosis, severity, and mechanism of each injury. Match exposures for individual players were recorded on a weekly basis. The loss of time from training and match play was used as the definition of an injury.

So, looking at those results of the criteria that we just discussed, the incidence of the injury was 91 injuries per 1000 player hours, and each injury resulted on average in 18 days of lost time. The recurrences which occurred for 18% of the injuries were significantly more severe, which kept the players out for 27 days and then new injuries which was 16 days.

The common occurrence of injuries was thigh hematomas, which were the most common injury for forwards and backs, and that was contact-based, the ACL injuries for forwards which was non-contact based, hamstring injuries for backs caused by greatest number of days in absence, which is also non-contact based, and then contact mechanisms accounted for 72% of the injuries.

Foul play was only implicated in 6% of those injuries. The scrum or the ruck and maul elements in the game that caused most injuries to forwards and being tackled caused most injuries to the backs. The hooker, which is your number 2 position. In the scrum formation, they are right in the middle of the front row of the scrum. They were the most common forward to receive injuries. They are at highest risk of injuries. The outside Centre, number 13 player, is usually the player who runs with the ball probably as an impact player. They were more likely to be injured in the back line.

Golf: Moving on to golf. Over the years, golf has become an increasingly popular sport, attracting new players of almost all ages and socioeconomic groups. Golf is practiced by up to 10 to 20% of the overall population in many countries. Beyond the enjoyment of the sport itself, the health-related benefits of the exercise involved in walking up to 10 kilometres and relaxing in a pleasant natural environment were often reported to be the main motives for adherence to activity by recreational golfers.

There is a moderate risk for a sports injury. However, excessive time spent golfing, the technical deficiencies lead to overuse injuries. These are two main causes of injuries among golfers, and each has specific differences in the pattern in which they occur in professional and amateur golfers. Golf injuries originate from overuse and traumatic origin. These are the two characteristics that relate to most golf injuries. It primarily affects the elbow, wrist, shoulder, and thoracolumbar sites. Again, we have got to consider that in the amateur player not striking the ball correctly and in the professional player, more the overuse or the chronic swing. Professional and weekend golfers, although showing a similar overall anatomical distribution of injuries by body segment, tend to present differences in the ranking of injury occurrence by anatomical sites. These differences can be explained by the playing habits and the biomechanical characteristics of the golf swing. Many of these injuries can be prevented by a presentation or by a pre-season and year-round sport-specific conditioning program which is presented to them and applied by each golfer. Muscular strengthening and flexibility, aerobic exercise components are a must, followed by short, practical pre-game warm up routines. Then the adjustments of an individual’s golf swing to meet their physical capacities and limitations through properly supervised golf lessons. Finally, the correct selection of golf equipment and an awareness of environmental conditions and etiquettes of golf can also contribute to making golf a safe and enjoyable lifetime activity.

Consider yourself as sports chiropractors, where would you fit into this chain of maintaining golfers?

Cricket: Moving on to cricket. Again, cricket was one of the first sports to publish recommended methods for injury surveillance in 2005 from England, South Africa, Australia, West Indies, and India.

While the incidence of injuries is about the same, the prevalence of injuries has increased due to game format changes, an increasing number of matches played, and decreased risk between matches. Bowling, which accounts for 41.3%, fielding and wicket keeping: 28.6%, account for most of the injuries. Acute injuries are most common, with 64 to 76% of occurrence followed by an acute-on-chronic at 16% to 22.8%, and chronic injuries, which sits at 8 to 22%.

The most common modern-day cricket injury is hamstring strain. The most severe is lumber stress fracture in the young fast bowlers. Instances of bone injury to the hand, chest, face, head, legs, and thighs have been recorded due to injury from impact by the ball on the batsman. Referring to the image on the presentation. A very famous South African cricketer over here by the name of Gary Kirsten was hit by the ball. You can see that it hit his helmet and you can clearly see the visor of the helmet there. The cricket ball went through the visor and fractured his cheekbone. Yes, he continued to play, but I think he regretted that decision in the later stage. Looking down, we spoke about that Australian cricketer who passed away unfortunately. This was the incident itself where he was struck on the back of the head by the ball. Again, a freak circumstance that happened but again has motivated for improved helmets and technologies for safety.

Baseball: Coming through to Baseball. Baseball, again, another high impact sport, large, weighty ball, hardened leather ball that is thrown at high speed, high velocities. I think it is thrown nowadays at over 100 miles an hour, which is an incredible speed if you think about it. It is an absolutely interesting sport to look at with regards to injury. The  impact of pathomechanics of throwing, presents the following issues.

Namely it is rotator cuff and ligamentous capsule injuries. They are common in young baseball players. It is important to understand shoulder mobility and stability as well as the biomechanics of throwing. This background information does make it easy for us to see how shoulder injury is really all part of progressive continuum and begins with instability leading to subluxation.

Can we avoid it? Can we prevent it? Can we make progress in it? Or can we make sure that in a later stage, they are not suffering with arthritis or issues that are further complications, and later impingement which can result in a rotator cuff tear. Besides history taking and physical assessments, they are crucial in determining where the patient might be on the continuum of play or pain free lifestyle.

Just following up on that, we have got to understand that accurate evaluation places the patient in one of the following 4 groups.

• Number 1 is pure impingement,
• Number 2: anterior instability due to trauma with secondary impingement,
• Number 3: anterior stability due to hyperelasticity with secondary impingement, and
• Number 4, pure anterior instability.

For example, this baseball pitcher over here. You can see how much he is severely hyperextended at the elbow joint, but also how much of external rotation has really formed up in the shoulder joint with our main horizontal abduction. This puts a lot of stress on the shoulder joint, thus it can end up being a severe shoulder injury if he continues to persist this way.

We have got to take a kinesiologic approach, which is the initial treatment of choice. It is the best preventative early treatment available and includes a specific strengthening program.

If this fails, as in only 5 to 10% of the cases, an anatomical repair is instituted. There are 4 basic guidelines when doing the surgery. We have got to maintain the muscle attachments and proprioceptive fibres. That would be our first or our gold metal. Second to that, do not shorten the capsules significantly. Number 3, build up the anterior labarum, and number 4, regain full range of motion quickly through adduction, splinting, and rehabilitation. We have got to make sure that the post-operative rehabilitation program is then diligently adhered to. This is that stage 4 or sport-specific rehabilitation that we should have in our minds. Also, if you do have the ability for biokineticists or for physical therapists, and to work with them to progressively help the athletes, it is always good to include them at this stage.

Conclusions on baseball. Finally, the injuries involving the hip and groin are relatively common in baseball players. Our knowledge of the mechanics of overhead throwing continues to evolve and as does our understanding of the contribution of power from the lower extremities and core. It is paramount that the team physician be able to accurately diagnose and treat injuries involving hip and groin, as they may lead to significant disability and inability to return to elite levels of play. This review focuses on hip and groin related injuries in the baseball player including femoroacetabular impingement or core muscle injury and osteitis pubis.

Horse Riding: We spoke about equestrian sports and especially we are going to take into account not only the falling aspect but the animal itself. Equestrian sports represents a variety of activities including a horse and rider. Due to the unpredictable nature of horses, their height, and their potential high speeds involved, equestrian athletes are at risk of head and spinal injuries.

Traumatic brain injuries, including concussions are more common than spinal injuries. Both injury types are most commonly related to a rider fall from a horse. Spinal injuries are less common but are associated with potentially significant neurological morbidity when spinal cord injury occurs. An improved understanding of preventable injury mechanisms, increased certified helmet use, improved helmet technologies, and educational outreach may help address the risk of head and spinal injuries in equestrian sports. Most equestrian-related injuries occur during schooling or long non-competitive riding. A large proportion of the injuries involve children and teenagers. We spoke about that earlier where we saw quite a large portion around about 39% were at or under the age of 19 years. In contrast, in many other contact and high risk sports, participants in equestrian activities are predominantly female and particularly at the recreational level. Horse-related injury is the eighth leading cause of emergency department presentation for sports and recreation related injuries in females worldwide, while the rates of overall injury from riding is rather low, with 2 per 1000 hours of riding, compared to other sports such as wrestling, where you see 10.7 per 1000 hours of exposures of football, 6.1 per 1000 hours of exposures, the track and field events was 5.7 per 1000 hours of exposure. The risk of severe injury from equestrian activities was considered to be higher than that of American football, motorcycle, and automobile racing.

Despite the high incidence of fractures reported in the literature, head injuries have been found to be the most common cause of prolonged hospitalizations and deaths due to horseback riding. In Australia, studies have reported an estimated mortality of 1 out of 10,000 riders, with 60% of these deaths from head injuries.

Floorball: Floorball is a very interesting sport. It has become a modified and more static version of roller and Ice Hockey.

The results: the injury incidents was greater in female players during preseason, with a 22.9 versus 7.4 with a P value of 0.01, game season with 39.5 versus 28.3 with a P value of 0.002, as well as the whole year combined with 33.9 versus 20.8 with a P value of 0.02. The thigh was the most common injury location in male players and ankle in female players. Overuse injuries were common among men and were primarily back problems. Traumatic injuries were more common in women, mainly knee and ankle injuries. Most injuries were of mild severity. A great number of anterior cruciate ligament injuries occurred in women with a numerical value of 11, than men with a numerical value of 2.

To conclude on that, the injury incidence is significantly greater in female floorball players throughout the entire floorball year. Male players sustained mostly overuse-based injuries, while female players suffered traumatic injuries. The majority of injuries in floorball were mild irrespective of player sex.

 

NFL: This is a large data field where the NFL spends a lot of funding on researchers and especially on injury management. Knee injuries are among the most common musculoskeletal injuries in US football players. The literature includes little information about the role of player position and risk for knee injury. Knee injury in elite collegiate US football players is high, and that type of injury varies by player position. There were 332 elite collegiate US football players at the 2005 National Football League evaluated with a 54% or 178 players that had a history of previous knee injury.

Current knee injuries totaled to around about 233 players. All players underwent radiographic examinations including pain x-rays and/or magnetic resonance imaging when necessary. All knee pathological conditions and surgical procedures were recorded. Data was analyzed by player position to detect any trends. We found that 86 players, 25.9%, had a total of 114 injuries. The most common injuries were medial collateral ligament of the knee with a number of 79, meniscal injuries with a number 51, anterior cruciate ligament or ACL injury had a number of 40 players who had surgeries. The most common surgeries were arthroscopic meniscectomy activities with a number of 39 patients, ACL reconstructions with 35 patients, and arthroscopic meniscal repair with 13 patients.

A history of knee injury was most common in defensive linesmen with 68% of players, tight ends: 57%, and offensive lineman with 57%. Knee surgery was more commonly performed on running backs with 86% and linebackers: 34%. There were no significant associations between the type or frequency of specific injuries with regard to player position. Knee injuries are common injuries in elite collegiate football players, and one-fourth of these players undergo surgical procedures. However, there were no statistically significant differences in type or frequency of injuries by player position.

American football is a collision sport and it is played by athletes at high speeds. Despite the padding and conditioning in these athletes, the shoulder is a vulnerable joint, and injuries to the shoulder girdle are common in all levels of competitive football. Excuse the fact that I put an ankle injury here where we saw ankle fracture, dislocation in this player. But again, the relevance coming through to this is how severe some of these injuries actually end up being.

Some of the most common injuries in these athletes include anterior and posterior glenohumeral instability, acromioclavicular pathology, including separation, osteolysis, or osteoarthritis, rotator cuff pathology, including contusions, partial thickness or full thickness tears, and pectoralis major and minor tears. Usually in pec major, we see more commonly the full thickness there compared to partial thickness.

In this conclusion, the study, we saw 1385 injuries occurred to hand, first ray, and fingers over 10 seasons studied. Of these injuries, 48% involve the fingers, 30% involve the first ray, and 22 involve the hand, with game injuries more common practice injuries at each location. There are metacarpal fractures and proximal interphalangeal joint dislocations, the two most common forms of injuries. Offensive and defensive lineman were the most likely to sustain a hand injury, with 80% of hand injuries being metacarpal fractures. The most common injuries to the first ray were fractures 48%, sprains 36%, which occurred most often in athletes playing a defensive secondary position. Finger injuries were most commonly dislocations at the level of proximal interphalangeal joints, typically involving the ulnar 2 digits. Finger injuries were most common in wide receivers and defensive secondary players. The act of tackling produced the most injuries at 28% of incidents.

Basketball: A total of 1094 players appeared in the database 3843 times, so that means 3.3 injuries per player in 2.6 seasons. Lateral ankle sprains are the most frequent orthopedic injury, with a number of 1,658 or 13.2% of cases, followed by patellofemoral inflammation with 1,493 cases or 11.9%. In lumbar strains, we saw 999 cases or 7.9%, and hamstring strains in 413 or 3.3% of cases. The most games missed were related to patellofemoral inflammation, where 10,370 cases or 17.5% of lateral ankle sprains, which were 5,223 cases or 8.8%, knee sprains or 4369 cases or 7.4%, and lumbar strains, which sat at 3933 cases or 6.6%. In conclusion of that, professional athletes and NBA experience high rates of game-related injuries, patellofemoral inflammation is the most significant problem in terms of days lost in competition, whereas ankle sprains are the most common injury. True ligamentous injuries of the knee were surprisingly rare, importantly, player demographics were not correlated with injury rates. Further investigation is needed regarding the consequences and sport-specific treatment of various injuries in the NBA players.

Ice hockey: Again, speaking that this is a mostly collision-based sport. We saw that injuries are related to direct trauma, with 80% of the cases happening, and overuse: 20%, most commonly caused by high velocity, aggressive stick use, and body checking. A participant cannot anticipate an injury after playing roughly about 7 to 100 hours of hockey depending on their age and activity.

Although facial injuries are common, they are decreasing because of adequate helmets and protection. Conversely, cervical spine injuries are being reported more frequently, and injuries to the upper extremity include acromioclavicular joint dislocation, scaphoid fractures, and gamekeeper’s thumb. Injuries to the lower extremity predominantly involve soft tissue with strains of the hip adductor, tears and medial collateral ligament of the knee and contusions to the thigh. Scientific studies have reduced injuries by providing improved protective equipment, strict rules, and enforcement of the laws effective to training and conditioning.

Lacrosse: Previous research has found that the location, type of mechanisms of injuries in lacrosse players vary by gender. The patterns and risk factors of injuries in lacrosse players are still not well known.

The study population consists of lacrosse players who utilized the accident medical insurance provided to US lacrosse members. Cluster analysis was used to explore the aetiology of lacrosse-related injury. Between 2002 and 2006, there were 593 game injuries, 496 were in men and 97 were in women.

Play scenarios resulting in injury were not determined by the position played.

In males, the primary injury mechanism was by contact either with another player, stick, or ball.

In women, body-to-body and stick-to-body and no contact were the most common injury mechanisms. In both genders, the majority of injuries occurred during legal play.

Swimming: It has been reported that 90% of complaints from swimmers was a sufficient magnitude to seek a physician’s advice pertaining to the shoulder. Problems with the hand and elbow occur less frequently and often can be attributed to a secondary cause. Epidemiological studies report prevalence rates of shoulder pain in swimmers ranging from 3% to 80%. The pain varies in location about the shoulder including anteriorly or anterolaterally, superiorly or posteriorly, and at the insertion of the deltoid.

It has been estimated that the average collegiate swimmer performs more than 1 million strokes annually with each arm. It is generally agreed that the repetition or overuse is a major factor in the development of shoulder pain, and that because not all swimmers develop shoulder pain, the overuse must be combined with a secondary insult. These insults must include supraspinous avascular tendinitis, biceps avascular tendinitis, impingement syndrome, labral damage, instability secondary to ligamentous laxity, and instability secondary to muscle dysfunction.

Given the varied and pervasive nature of shoulder pain in swimmers, it is unlikely that any one cause can adequately explain its prevalence. Shoulder pain in swimmers has multiple causes including those mentioned above, along with recognized causes of shoulder pain in older populations such as rotator cuff tears, calcific tendinitis, adhesive capsulitis, glenohumeral arthritis, acromioclavicular arthritis, scapular thoracic inflammation, and cervical disease. In swimmers, however, we believe that most shoulder pain is caused by instability stemming from demands that are specific to the sport of swimming. The inflammation can lead to swelling and scarring which can result in further inflammation and perpetuation of symptoms. By understanding how these demands contribute to reduced stability of the shoulder, a rational plan can be formulated for treating and preventing swimmer’s shoulder.

 

[END]

English Direct Download PDF ICSC09 _Section 7_Biopsychosocial Considerations

ICSC Culture Diversity Module 09
ICSC09 _Section 7_Biopsychosocial Model
Instructor: Thomas Ventimiglia
Video Lesson: 00:58:00

Welcome to the Biopsychosocial Model in Sports to Chiropractors’ Role.

Health in sports is all about being ready to compete. That is a little different definition than most of us are used to. Primarily, the one that we all use and the one that most organizations and provider groups, and payer systems use is that health is a state of complete physical, mental, and social well-being. Not merely the absence of disease or infirmity. This was developed by the World Health Organization in 1946.

Some thirty-odd years later, Dr. George Engle, 1977, super bright guy from New York with advanced credentials in medicine, he reasoned that something that we as chiropractors knew from our teaching was that pretty much, health is really a confluence of psychological, behavior, and social connections. This became known as the Biopsychosocial Model. That very model is the one that some would argue was built off of the works Palmer. B.J. Palmer’s works, when he originally discussed chiropractors’ view of what health is and he referred to it as a Triune of Health that highlights the independent nature of the physical, mental/emotional biochemical, and structural influences on health.

In the Sports Community, health for the athlete is the ability to compete. By and large, most of us have not entertained the concepts of the biopsychosocial model or the elements as they relate to the athlete. That is pretty much what this lecture is about.

My name is Tom Ventimiglia. I am a graduate of New York Chiropractic College, class of 1980. Professional education through NYCC. Private Practice, almost 40 years in Queens, New York. I retired from the New York Chiropractic College, which is now the Northeast College of Health Sciences as the dean of the Department of Postgraduate and Continuing Education. I am an active member of the American Public Health Association of Chiropractic Health Section, an active member of the Federation of International Chiropractic Sports, and I am a member of the National Chiropractic Mutual Insurance Company-Speakers Bureau.

In the elite sports, which is what most of you will strive to or already are in that community, health problems do not have anything to do with the psyche or the environment. By environment, we are talking about the social environment. If all health problems in our sport can be traced back to either traumatic or orthopedic causes, that is the model that is generally recognized in sports medicine.

Take a moment, think about it, reflect on it. Are all the problems that the patients that you see, whether you are treating the athlete, are they by and large problems that have nothing to do with the psychological or sociological aspect of the athlete’s life, and they are pretty much all traced back to some traumatic or orthopedic cause?

Do you Strongly agree, agree, neutral, disagree, strongly disagree.

It is perhaps more important for you to reflect on this question because as you approach this question and as your answer is framed, it pretty much defines how you are going to approach the topic. More importantly, how you are going to approach the next patient that you see who an athlete is.

The purpose of this lecture is to introduce you to the biopsychosocial elements that are unique to the professional and the elite athlete, discuss a self-reflective technique called critical consciousness, and then apply the knowledge and create an empathic, supportive patient encounter that guides the patient athlete towards a greater sense of health and well-being.

The learning objectives will discuss the biopsychosocial model, how it influences, the professional-elite athlete; understand the cultural influences that impact the patient-provider relationship. We are going to begin to leave the biological and enter into the psychosocial. You, the doctor, are a key player in this transition. That patient, that athlete, whether they are professional or whether they are weekend warriors and a whole human being. In the case of the professional-elite athlete, there are forces at play that will impact their ability to become healthy. Finally, we are going to talk about a concept called critical consciousness, cultural awareness of the patients that you are treating. By and large, we have a diverse patient population in the athletic community. How you approach them, how you approach your patience has a tremendous impact on the care that they receive.

The biopsychosocial model of health, which is Engle’s model gave us a very broad understanding of the factors that cause particularly non-communicable diseases. It influenced the way we practice. It also created the beginnings of what would become known as the integrated disciplinary teams in health care. You may already do this at your private practice. You certainly do this when you are treating athletes, whether it is in college or high school, or professional, or elite. That integrated disciplinary team is what has evolved from the work of Engle.

This is the general idea of what the biopsychosocial elements are. There is the biological, genetic, physical activity, ability, disability. There is the mental aspect, temperament, self-esteem, coping skills, social skills, family relationships, as you get into the social elements, family circumstances, school, peers. These are elements that all come and mesh together, but they have an enormous impact on the patient-athlete. How do they equate when we are talking about a model of health where health is defined for the athlete as the ability to compete?

That was not Engle’s original discussion, that is not what the World Health Organization discussed. This is the definition of health according to scholars as it relates to the professional and the elite athlete.

This is a study that was published in Washington School of Medicine. This study gives you an overview of what the biopsychosocial model is. That is our friend Engle. Simply put, biologically, it is associated with disease and certainly, pathology, genetic disorders. In sports, it refers to traumatic injury, and it refers to pain, and of course, acute and chronic pain and dysfunction. That is the biological element. Keep that in mind as we move on this journey about caring for the athlete.

Psychological speaks about the emotional wellness and mental wellness of the athlete. In this case, we are talking about three things. We are talking about anxiety, depression, and health behaviors. Anxiety, depression, and health behaviors that lead to disease and illness.

The social element speaks about the family relationship. Being an athlete often functions in isolation and how that impacts the individual. I have taken this one step further because this concept of social influences on the patient’s health have very much been part of the evolution of organizational and institutional, and very often governmental perspective on the impact social influences have on health. It is referred to as social determinants of health.

I urge you to Google that and get an idea because it is the social determinants of health that started to quiet things that impacting the patient and, in our case, professional or elite athlete. That is family, their education, their economic level, their access to care, health care. Sometimes, the only access to health care the college athlete has might very well be through this sport.

Food insecurity, these are determinants of health that was sociological in nature, and they have a traumatic influence on the patient’s outcome. How they impact the athlete? That is what we are going to talk a little bit about. 

The concept of the social determinants is being championed by the Centers for Disease Control and prevention. That is the website you want to go visit to get a better understanding of these influences.

This is from Health In the Elite Sports published actually in the German Journal of Sports Medicine. It is interesting because it is a universal view of the patient that we are treating. Health, injury, and illness in the elite sports are closely connected with social factors. We do not think about it that way because all we are thinking about is that football player crashed his head into the other players and now, we have a concussion, we have a severe neck, injury or spine injury.

This is the work of health, injury in sports. First, the term health in the context of elite sports is directly linked to the ability to perform or compete. We need to switch our perspectives a little bit when we talk about heath in elite and professional sports. Secondly, the ability to perform on top level with the highest priority as it relates to health-related decisions.

Is that your priority when you are treating the athlete, to get them back into the game, return to play at the highest level of their performance? That is what this study found. We will go over a little bit about how the study was constructed.

The individual’s perception about their complaint such as pain, which is predominantly with the athlete walking off the field, whether walking into your office, is strongly influenced by what is called the culture of risk. If you have never heard of that, you see it all the time. That is where the athlete has a very high pain tolerance. The reason that is not necessarily from a physiological standpoint.

Remember pain is psychological as it is physiological, but it is also the culture of being a professional or elite athlete.

They take higher risks to succeed in their competitions than the average individual might. It is caught in a permanent action dilemma namely between the necessity of risk and taking care of their health. That is the dilemma the patient walks into you. They are walking in with perhaps a shoulder injury, but keep in mind, the underlying psychosocial elements about their healing journey. These are forces at play.

This culture of risk is characterized by normalizing the occurrence of injury and accepting the inherent risk of sports. How does that change your view of the patient’s care? Does that mean you endorse this model to be part of the culture of risk? I suggest we all are to a greater or lesser extent because we want to A, please the patient, and B, get the patient back into what is “a normal life”.

Keep in mind that if you look at the patient from a psychosocial component, this does not mean that you are going to minimize their desire to get back into the game, but rather you might very well, through exploring the psychosocial components, finding a way for the patient to address A, the injury, and B, compliance with your treatment plan, C, self-care. What a powerful set of clinical tools you have by just stretching out of the biological and looking into the psychosocial.

Question. Physicians and coaches often focus on the biomedical aspects of injuries and complaints, and they rarely try to integrate different understandings of health. The consequence is that relevant factors in the genesis of injuries and complaints are ignored.

Do you strongly agree, agree, neutral. disagree, strongly disagree.

Do we ignore the psychosocial elements in the patient’s care? If we do, this creates a disconnect between the doctor and the patient. Your patient is a whole human being physically, mentally, socially, and in cases, spiritually as well. 

I want to spend a little time about the methodology and conclusions that were reached based on the study that we are discussing. They looked at 1138 young athletes. There were male and female. They had a 61% response rate to their service, which is very good for a survey study.

The survey looked at their health status, their health-related behavior, representation from outside of the sports community, their understanding of nutrition, social network, and socio-demographics. The study also looked at, specifically, for Olympic disciplines. Artistic, gymnastics, biathlon, handball, and wrestling. They did interviews on the athletes. They observed the health-related behavior of the athletes, coaches, and medical staff during training and competition, and they analyzed Olympic Training Center. This is an interesting study that was done.

This was predominantly one example of Klaus Schneider who happens to be not the patient athlete’s name, but this is a handball player. These are the physical injuries that he sustained as being an elite athlete. As you can see, infraspinatus strain, lacerations, splintered thumb bones, hamstring muscle strains, meniscal lacerations, quad strains plantar fascitis. Physical ailments that the athlete sustained particularly in this case, and you will find as you know, depending on the sport, different injuries for the sports.

This is the result of the study. The athlete’s complaint does not necessarily correspond with the injury or how much time they need to take off. There is a disconnect immediately. You may see this as an acute sprain or acute sprain strain perhaps in this 2 or 3 gradings, which you know is approaching surgery. That is not how the athlete is going to communicate the amount of pain because remember, the culture of risk, I have to deal with pain. It is part of being an athlete.

Of course, the subjective complaints decrease with increased therapy and reduced competition, less therapy. Most of the injury history is ignored, it is trivialized, and in many cases, it is masked with pain medicine. That is the findings of the study.

Social function for the athlete is the ability to compete. Remember, they are part of a team or they have achieved a certain level of expertise recognized by coaches and the individuals, whether it is NCAA, whether it is professional. Once they hit that level, they are part of a society. Most athletes maintain their social functionality, despite being diagnosed, and of course, this can lead to greater injury or more severe injury, greater complaint.

They do not want to be placed in a category as not having stamina or endurance. This becomes part of that socialized culture of risk. Very often, they will transfer the responsibility of their health to their coach and/or you as to healthcare provider. They do not take that responsibility on themselves. “Doctor said” that is the key. You play it a pivotal role in moving this athlete toward a state of health. That does not mean, you are not moving them towards a state of being competitive. It simply means you are taking a different approach than many, many other healthcare professionals do.

Who do we serve? These are our patients. There is multi-cultural, there is multi-gender, different sports. We are treating all the athletes. It is different abilities, different levels of trauma. This is what we need to understand as we move forward.

This is a look at the psychological aspect of the patient’s care. This study was about the mental health of elite athletes, and this was a narrative systematic review. We will move from the biological into the psychological. The physical impacts of elite sports participation have been well documented but quite frankly, nobody has done any studies on them. The studies are very, very few. Most of them have not been interventions, but they are simply overviews and surveys.

Based on the evidence, they found that broadly speaking, athletes have the same level, comparable risk of high-prevalence mental disorders relative to the general population. This occurs as they approach retirement, or they are experiencing performance difficulty. Think about that, your patient is an older patient, perhaps coming to the final stages of their career. You might want to think more about the mental health of this individual, but also, if they are struggling with performance levels. That is when the mental health component comes in.

The intense mental and physical demands on the athlete are unique aspect of their career, and that makes them susceptible to mental health problems and challenges and taking higher risks. You need to know that. They tend to not seek support for mental health problems for all the reasons that people usually say, “I am not going to see anybody in the mental health field” because in this case, it is a perception of weakness.

While it is well-established that physical activity contributes to the well-being of the individual, in the case of the elite-professional athlete, it often compromises their well-being, their approach to the mental health. It increases the symptoms of anxiety, depression, overtraining, which is a behavioral issue. Of course, injury and burnout.

This study took a look at a few different athletes and see what we came up with from the mental health perspective. This is a Rugby team in Italy. The players experienced a moderate frequency of anger symptoms, interpreting these as facilitative rather than debilitative. In other words, their anger as a good thing. It facilitates their skill sets and makes them more competitive. By and large, anxiety is a significant predictor of anger.

Here is where I want to go with this, self-confidence was a significant predictor of control of anger. Self-confidence. One of the things that I am going to move towards as we go through the rest of this lecture is how we doctors can facilitate the patient’s, the athlete’s sense of self-confidence, self-efficacy.

That is more than treating the biological now, is not it? It is guiding them and what tools we need to do then. There is a wonderful book, I will mention at the end, about motivational interviewing that will help you frame communication technique that will help the athlete move towards a sense of higher confidence. High and low-level competitors did not differ in their frequency and interpretation of anger symptoms.

This is various sports in Norway. Females have higher level of concentration disruption and somatic anxiety than males. The perception of performance climate predicted performance worry. Perceived ability predicted less performance worry for females and males, perceived ability. Here we are again, self-confidence, perceived ability. There is no secret here other than the fact that we, by logic, ignore these issues. How can we get the patient, the athlete back to that place of understanding their level of confidence and their performance and skill, and what they can do without hurting themselves, without overtraining? That is part of the job of addressing the psychosocial components of the athlete.

These are swimmers. Greece facilitated perceptions of anxiety symptoms related to more adaptive cognitive and behavioral outcomes. Different sports, different approaches to the issues of anxiety and depression that plagued many of the general population, but also plagued many athletes. They perceived anxiety as a facilitator, and they had less avoiding coping strategies. They did not perceive anxiety as a debilitative issue. They saw it as a facilitative issue. Think about that when you are speaking with your patients. Has anxiety become part of their norm, lack of sleep, use of alcohol when you are not performing or not competing, other drugs? 

Guide the conversation. We are not talking about being mental health specialists. Do not misunderstand me. That is when you need to make that referral. I am just talking about, how you develop a relationship with the athlete that expands the skills, but also expands the relationship that you have with the individual.

These were various sports. Self-esteem based on respect for self is associated with more positive patterns of perfectionism. Their self-esteem. Negative patterns of perfectionism were related to higher levels of cognitive anxiety and lower levels of self-confidence. These are behaviors things that you could focus on that build the confidence of the athlete.

By the way, this all happens very quickly during the care of the patient. You do not have to spend one hour with the patient. You do not have to have a separate consultation. While you are examining, while you are adjusting, while you are overseeing the rehabilitation, have a planned conversation that addresses these issues, and suddenly, the relationship changes. Be more than a therapist, be their doctor.

One of the interesting things is that mental health challenges for the athlete are often related to a lack of social support and/or recent life events. This is something that keep in mind for the professional athlete or the college, just high school athlete, the elite athlete particularly. We will talk about this. The social networking that gives support to the athlete is related to the activity, but the family stressors and the other issues that most of us ignore because simply, this is not part of the athlete’s life. There are also issues that play. I suggest, probably a good thing to find out from the patient, how are things going at home? Remember, doctor build a relationship. The athlete, regardless of their level, really would like to have a relationship with you. Somebody who can guide them on health issues

Here is a various Sports in Australia. Results suggested that athletes have a higher prevalence of eating disorders, especially in sports, emphasizing thin shape, leanness, or low weight eating disorders were higher among female athletes, competing emphasized the importance of a thin body. Keep in mind, when you are treating this patient population, ask the question, discuss their eating habits.

I am going to add, and again, this would be part of the motivational interviewing work if you decide to pursue it and I urge you to, it will change the way you communicate with your patients. Find out a little bit about their healthy eating patterns. Just giving them a diet does not work. Although, it is important if they do not have an understanding of nutrition. More importantly, is the health behavior. I will say it again, more important is an acknowledgement on their part of their health behavior.

Let us look at social determinants of health, particularly in the athlete. These are access to healthcare education, economic stability, social, and community support. Within that context, neighborhood and their environment.

Athletes are people coming from different walks of life. Negative social determinants preclude development of positive health over time and lead to health disparities. They have a tendency to have the greatest impact on adolescent. If you are treating high school, athletes and young men and women, particularly in college who are moving through the system as a gifted athlete but suddenly, they are not moving with the maturity that the average individual might, this has an impact.

African Americans and black athletes are particularly vulnerable. This is disproportionately represented in sports. They rely or have families relying on them for financial stability. Knowing that, talking about that is gaining a better understanding of the social influences that the individual is dealing with.

Underserved athletes, involved assessing social determinants of health because you want to get a better understanding of their needs, the health disparities that impacted and of course, the influences such as their family.

Sports Medicine Physicians. They represent the only clinicians with whom athletes would engage for health care. You may be the only doctor who is taking care of them. Broaden your perspective. Do not just look at the injury. Be the whole doctor and as chiropractors, I know, we are trained to be more holistic. One of the ways that you can screen for social determinants of health is ask, how are you doing, are you stressed, how are you handling stress, how are things going with the family.

One of the things that I found as a chiropractor, that really worked beautifully for me, in this relationship, in this conversation, while I was treating the patient, while I was administering the adjustment. I was talking to the patient about these topics. I am caring for you, biologically, we are having a conversation and I am learning a little bit about any mental stresses that you are under and I am getting a better understanding of who you are as a person from your social determinants. Have a plan when you are caring for your patient. That is more than logical.

The athlete according to this particular study, often just like the doctor, the healthcare professional, is concerned about their well-being. By you participating in this conversation, you can better facilitate them on the playing field because they have somebody to work with more than the coach. While you are doing the physical exam, follow up. I said earlier, while you are doing the treatment. Many of us believe that we understand the emotional problems that our patients are dealing with. We can deal with the non-injury psychological issues. We just need to step into that role. Do not miss the opportunities. Take time. Have a plan, work with the patient, look at the intake information, maximize the time you are spending with them.

Question. I feel confident discussing psychosocial issues with my athlete patients.

Do you strongly agree, agree, neutral, disagree, strongly disagree.

We talked about the biopsychosocial model, the biological aspects of it, about the psychological aspects that like anxiety, depression, about health behaviors that are influenced by the lifestyle that the professional and elite athlete have. We talked a little bit about these social support systems, about the culture of risk, the life as it relates to health and well-being of the athlete is not exactly the same as it is for the general population.

I want to take this conversation a little further along. How we develop as people, our values, our belief systems, that is what we bring often to the doctor-patient relationship. Unfortunately, one of the things we bring is our bias, whether they are implicit or explicit. We also bring our stereotype. It is inevitable.

Kahneman wrote in a really great book called “Thinking Fast and Thinking Slow”, wonderful book. Think, read, and learn about the cognitive bias that we all experience. When this bias appears into our consciousness, they translate into our behaviors. Here is the thing, our purpose as healthcare professionals, specializing in sports, is to help the athlete achieve optimal performance naturally. That is Chiropractic. That is the purpose that is articulated by the American Chiropractic Board of Sports Physicians.

FICS purpose is articulated as to provide equitable access to sports chiropractic care, education, mentoring, and research to all athletes regionally, nationally, and internationally. We have an opportunity to fulfill a mission that is clearly well-described by expanding our skill sets and including the psychosocial elements in the care of our patients to promote equitable access to healthcare for all athletes.

Here is where we are starting. This is a quote by Anais Nin. If you would like to Google her, she is an author, writer early 20th century “We do not see things as they are. We see things as we are.” That is a very profound statement because when we are dealing with our patients, our athletes do not look anything like us. Keep in mind, no matter what religion you are, no matter what gender you are, race, ethnicity, socioeconomic level, even if the athlete was born in the same house as you or in the same neighborhood and looked identical to you, chances are you have different value systems. Think about any members of your family.

We engage with our patients through our lenses and I am asking you to not be blind. Be conscious. Maya Angelou said, “We are only blind as we want to be.”

Cultural humility, how do you effectively and respectfully deliver health care to an increasingly diverse population of elite- professional athletes, and it starts with a self-reflection and humility.

Critical consciousness. That is how we overcome our biases, stereotyping, and prejudice. It is not easy. It is a lifelong experience. You will know it when you feel it. When you look at somebody who is obese, and you have a thought about their obesity, you look at somebody who has a different sexual orientation, and you have a thought about that.

You put it aside. You are a doctor. You are there to take care of them. It creeps into your mind. Unless you are critically thinking about that and reflecting, and it is a lifelong process. It will always be there. Sometimes it will cause, as Kahneman said, an unhealthy reaction, even you doctor in the care of that patient.

Just some definitions. Bias is the action of supporting or opposing a particular person or thing in an unfair way, allowing personal opinions to influence your judgment. This can be unconscious or implicit or conscious explicit. It shows up when you are challenged, when our way of approaching an issue, especially as doctors, is not followed, the patient is not compliant, the patient is not getting better. That is when these intelligent and then explicit bias begin to show up.

Equitable access to healthcare. Everyone is entitled to health and health care, regardless of their background. It is an egalitarian approach to health. We need to approach every patient from that perspective. Equitable health care includes healthy food, safe living environment, the ability to be well across all aspects of life from work home, life to medical care. What is health equity in sports medicine and how can we address health equity?

Stereotyping involves associating a characteristic with a group as a preconceived idea. Now, I know these terms are familiar to you. I am just telling you, urging you to think about when they are sitting in the room with you and your patient. Your job is to be self-reflective

Some studies I found that I thought were interesting relative to provider bias, in this study, they found that healthcare professionals who are white had a preconceived notion of pain assessment and pain tolerance than patients, who are of color. This led to unequal treatment related to pain.

These are the bias that are prevalent in healthcare, sexual identity, sexual agenda, education, socioeconomic status ableism, age, overweight and obesity, racial bias, geographic location. You think then though none of these plays into part of my role. I have a very open understanding and consciousness of people. Keep in mind, we are all human and under stressful situations, we want to make sure that we keep the patient’s well-being and welfare in mind. 

There is cultural awareness with your patients. Studies have found that patients from lower socioeconomic levels, the doctors had less conversation about alcohol and drug addictions than from highest socio-economic levels. Thinking about your athlete, an athlete comes sometimes from a lower socioeconomic level, sometimes from a higher socio-economic level. There was a study that showed that most white athletes were coming from who were professional or elite were in private universities.

Talk to some more dominant in conversation with African American patients. Nonverbal unconscious biases are observed that healthcare professional makes less eye contact with minority patient, especially with a weight status or sexual orientation. Medical Physicians prescribe less analgesia for Latino patients, for no other reason other than the fact that they are Latino. This cognitive bias is prevalent in sports medicine, and they cloud our decisions.

Our patients, on the other hand, have an expectation from the healthcare provider that somehow you are going to fix everything for them. We must learn that cognitive bias and mitigating strategies in our schools slow down decision-making and consider alternate diagnoses can be effective and know your own cognitive bias and how it impacts your decisions.

Here is the top five unconscious bias in healthcare: race, ethnicity, age bias, gender bias, weight status, and socioeconomic level. This encompasses all of us. If you are 35 years old and you are taking care for an athlete who is 5 or ten years older than you, be conscious of the fact that you might default to an age bias. Be conscious of the fact that you may have an objection to people who do not manage their health by virtue of their diet. As I mentioned, there are false beliefs about the biological differences between blacks and whites as it relates to pain.

One of the areas I had like us to be very conscious of, in over the next few slides, is how we approach our patients who are different than we are. This is so important, not only in private practice. It is equally important when treating the elite-professional athlete. We need to bring an open mind, I refer to as an egalitarian approach, to our patient’s care. I want to give you some examples of biases and prejudices that occurred various groups and perhaps you can identify with them, perhaps you find them disconcerting. More importantly is that to you they are there, they exist, and we need to do our very best to mitigate them.

Women and gender bias. Research have found that in some counties, it takes significantly longer for emergency medical personnel to get women to the hospital who are having heart attacks compared to men. Doctors are more likely to believe that heart problems for women are stress-related, whereas for men is always organic. Women of color, especially, are subject to inferior care as it relates to heart medicine, EMS travel.

Women endure a higher levels of intimate partner violence, accessing mental and family health services. Clinicians underestimate pain in women, which prevents them from receiving appropriate care. Now, while biology plays a role for sure, it is also important for us not to misidentify based on women or gender.

Sexual orientation. How do you address the individual? This author is saying, “If you do not know, just ask.” Instead of saying, “Are you married, or do you have a boyfriend or girlfriend”, consider asking if you have a partner, are you in a relationship, what do you call your partner? Members of the LGBTQ community are more likely than their heterosexual counterparts who experience difficulty accessing health care. There are less employer health-sponsored insurance benefits for same-sex partners.

We can make changes to the clinical encounter that can enable us to improve the health and well-being of our transgender individuals, communities. Soliciting and using the patient’s preferred name and pronoun, including sexual orientation/ Include gender identity questions on the intake forms. Include assessment of known risk factors among transgender populations. Consider some of our patients who are transgender might be taking hormone therapy or have postural alteration to conceal sexual characteristics, binding practices, which impacts the musculoskeletal system. The greater our awareness and sensitivity to our patients, as individuals, the greater our capacity to help facilitate their healing process.

Individuals with weight status problems. Obesity, bulimia nervosa, anorexia nervosa. This is not, in fact, only women. Trying to approach it from a person being lazy or just stop the thoughts and get a handle on your situation does not work. Imagine if you were consumed with the idea of food all the time. It is important and I had pointed this out to those athletes where leanness or body type is an essential part of the athletic activity. That you had to be conscious of the sport of the individual, and how that might play on their body size and eating disorders.

Critical consciousness. It is about human dignity. We can champion this. Doctor, we have an obligation and a moral responsibility to champion human dignity. In private practice, practice for care of the athlete, or will you call the pain to go by another country, or take care of a world-class elite-professional athlete? Remember, human dignity transcends everything.

Automatically activate an egalitarian approach. Equal concern, equal care, equal access to healthcare resources. Find common identities. It is still easy to see how we are different, but doctor, it is so much more important to find out how we are the same. We all have similar family traditions and values and beliefs.

I am suggesting to you as I have numbers of patients over decades of private practice, this all happens while rendering, chiropractic care because it is a plan that you have. If you have a plan for the physical, have a plan for the psychosocial. Take the perspective of the patient. There are fears, expectations, illness centered communication.

Illness is what the patient believes is wrong with them. The disease is what the name of something you give them. There is a story that says the patient in our case, it might be the athlete walks into your office with an illness. There are all the influences that are impacting this symptomatology.

They got hurt and in pain. Are they going to lose their position on the team if they lose their scholarship? Are they going to lose the support of their family or going to stay on the team? Those are the things that craft and create the illness. They come to our office, and we give them the name of something and now, they have a disease or disorder or dysfunction. When they leave your office, they have an illness again. Try to remember that and try to bring them into one continuum so that you are always conscious of the illness as well as the disease.

Cultural humility: Addressing inequities, providing a better health care experience for the athlete, professional, or elite. It is a lifelong commitment. Continue to evaluate yourself, take a breath, take a moment. Chances are, you have come from a station in life and chances are, you are in a station of life that is higher than the average. That bring the humility that comes with that level of success.

Understand your implicit and explicit bias. Keep it in check. There is a power in balance that is inherent in the provider-patient relationship. Remember that. That sensitivity allows you to have a much more authentic conversation.

Develop mutually beneficial and non-paternalistic partnerships with the patient. Non-paternalistic. Yes, you must inform and direct, but you can also guide. Here in this is the key to great communication, being a guiding force in the patient’s care. 

Understand your patient’s health, their beliefs, their life experiences, socioeconomic level, their dominant language, race, ethnicity, sexual orientation, age, gender and their health literacy. Even if they are exactly the same as patients yours, chances are, your patient’s disorder or disease is different. Cloak your relationship in humility. It ensures the patient feel safe. Safe enough to tell this story, our story, his story of illness and wellness.

Here are a few final thoughts. Gain a better understanding of the biopsychosocial model. Incorporate psychosocial assessment into your patient encounter. Take time to reflect on your personal bias, implicit and explicit. Develop communication skills that will enable you to contribute to the athlete’s journey.

I urge you, to take one more step with this one book that you read in the next month or two. This is the book you should read, Motivational Interviewing in Health Care. It is applicable to private practice. It is applicable to the care of your patients, who are athletes and professional athletes, and elite athletes. It is applicable to your role not only as a doctor but also as a coach, as a mentor, and as a healer.

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