The Sleepy Athlete: Effects of training and competition on the sleep of elite athletes: a systematic review and meta-analysis

The Sleepy Athlete

by OrthopedicsSport

Sleep and athletics. Athletics and sleep. We know that sleep is important. We know it is tied very closely to performance. We know that during sleep procedural memories are consolidated, immune responses are augmented, and anabolic metabolism is upregulated. There has even been a positive correlation with sleep duration and injury risk in adolescents…

The British Journal of Sports Medicine published an article (2018) looking at how the demands of competition and training affect sleep. 

Fifty-four studies were included (1997 – 2018) looking at sleep:

  • the night of competition,
  • the night before competition,
  • with the effects of training schedules,
  • with the effects of training load,
  • with the effects of hypoxia or altitude, 
  • with air travel
  • with the use of electronic devices

So, if we’re looking to achieve the highest attainable performance level when competing, we need to manage the factors that affect sleep and sleep quality as best we can. 

After a hard night of competition? Athletes rarely achieve total sleep time and/or sleep efficiency recommendations the night of competition. This is often attributed to a delay in bed time, as well as increased circulating cortisol, sympathetic hyperactivity, elevated core body temperature, muscle pain/soreness, and post competition arousal. 

Do the “nerves” get you? Regarding the night prior to competition, there was not consistent evidence from the systematic review to suggest sleep disturbances among athletes. It appears that there may be a subset who are more susceptible including individual athletes and those who compete in aesthetic sports.

Getting up early to train? Although athletes try to offset early morning training by going to bed earlier, this is rarely accomplished. Thus we see a reduction in total sleep time on nights prior to training when training commenced at or before 7:00am. The results indicate that most athletes go to bed about thirty minutes earlier, but get up about 90 minutes earlier resulting in a net sleep debt. 

Pouring on the coal? It was found that training load increases greater than 25% were correlated with decreases in total sleep time and sleep efficiency. This is thought to occur secondary to increased circulating cortisol and sympathetic activity which may prevent the normal down regulation of the human stress systems. 

Traveling high to compete? Exposure to high altitudes (over 2000m or 6500ft) and hypoxia had negative effects consistent with previous literature demonstrating lighter, more fragmented sleep. Interestingly, these are attributed to arterial desaturation (and thus a hyperventilatory response) and sympathetic hyperactivity. 

How about traveling by plane? Both late night and early morning flights were found to negatively affect sleep. Interestingly, eastward travel found decreased total sleep time while westward travel provided increased total sleep time upon arrival. Eastward travel appears to be more disruptive to sleep.

What about the devices?? We know blue light can cause sleep disturbances and delayed bed time and reductions in total sleep time was been associated with electronic device use. However, a study looking to reduce electronic media use after 10:00pm did not improve sleep habits in high school athletes. 

When we’re looking to promote of every possible advantage in competition, good sleep is an irrefutable component to focus upon. Knowing what factors may contribute to performance and how to modify these for success can be crucial. 

Thanks for reading!

Throwing Athlete - Return to Sport as an Outcome Measure for Shoulder Instability

Shoulder Instability: Surprising Findings in Nonoperative Management in a High School Athlete Population

by OrthopedicsSport

I speak from personal experience when I say that there is nothing like the experience of dislocating a joint. It’s as if your body knows something is really, really not ok followed by a certain nausea deep in the pit of your stomach. Having been through over 100 dislocations and two shoulder surgeries, I feel a deeper connection and sympathy for those experiencing shoulder issues and pathology. Being such a complex joint, there is also a deeper understanding of the complexity and individualized nature…

When considering high school athletes (…and where my shoulder and Physical Therapy journey started), The American Journal of Sports Medicine published a recent article looking at conservative versus surgical treatment for shoulder instability and return to sport.

Shanley et. al. (2019) looked at 129 scholastic athletes over 4 years. Interestingly, 85% of the nonoperatively treated and 72% of the operatively treated athletes successfully returned to the same sport without injury for at least 1 full season! Those within the nonoperative group that failed, 11 of 15 individuals, went on to operative care with 82% of the athletes successfully returning to sport by the next season.

Consider, more of those treated nonoperatively returned than those who were treated operatively. AND, if the nonoperative didn’t work – the athlete could still have the surgical intervention afterwards!! If this doesn’t speak to physical therapy first, I’m not sure what does!

Keep in mind that the athlete was run through a high-quality, multi-disciplinary rehabilitation program with a stringent return-to-sport clearance. Return-to-sport criteria included: absence of pain at rest, with training, or during activity; the absence of an apprehension sign; symmetrical shoulder range of motion (90% of unaffected side); a 67% external:internal rotation ratio within the affected extremity; and the ability to load upper extremity body weight during functional movement without apprehension.

Thanks for reading!

Dry Needling vs Corticosteroid Injection for Plantar Fasciitis Threshold Physical Therapy and Performance

Dry Needling vs Corticosteroid Injection for Plantar Fasciitis?

by OrthopedicsPain And Its ManagementSport

It’s there again… That pain in the bottom of the foot at the heel. Standing up in the morning is pure agony, like a hot butter knife cutting into the bottom of your foot. Maybe it’s better to just stay in bed? Too bad someone can’t just roll you into work today…

Everything was fine until you picked up that spring club sport again. It just seemed like a good idea at the time with the weather being so nice. At least the pain will calm down after a bit of limping around here this morning. What was it called? Plantar something-or-other…

What to do? What to do??

Plantar fasciitis (acutely) or plantar fasciosis (chronically) is a fairly common problem. Often reported as a stabbing or tearing pain in the bottom of the foot (plantar surface) and is worse with the first few steps of walking when getting up in the morning. It can also flare with longer bouts of standing, or when raising after sitting for longer periods. Often it is worse after exercises, as opposed to during. 

Treatments for such symptoms and a diagnoses have been noted to include calf and plantar fascia stretching exercises, local injections of corticosteroids and botulinum toxin, extracorporeal shock wave therapy, ultrasound scanning, radiofrequency ablation, cryopreserved human amniotic membrane injection, taping, and endoscopic release. All that being said, optimal treatment continues to be debated.

A recent (2019) study by Esat et. al. in The Journal of Foot and Ankle Surgery compared corticosteroid injection versus dry needling with some interesting results.

Wait, so they might stick a needle into the bottom of my foot?? Frankely, it’s not as bad as it sounds, and this is a case where size does matter… Dry needling needles are smaller!

So what do we know now that we didn’t know prior to this study? Well, with patients suffering from plantar fasciitis being assessed at three weeks and six months post-treatment, the differences might be surprising. Interestingly, the corticosteroid injection group showed a significant loss of efficacy at 6 months. However, in the dry needling group, there were no significant differences in results between the third week and sixth month. 

Dry needling was as effective as the corticosteroid injection at three weeks without the risks of the steroid (plantar fascia rupture, local infection, and fat pad atrophy) for pain, disability, and activity limitations. Not only that, but it outlasted the medication with better outcomes at six months! 

The authors note that this study should lead physicians to consider needling and further research should look at whether the key point in treating plantar fasciitis is peppering into the fascia or the induction of microbleeding.

For those that want to geek out just a bit more:

  • Although corticosteroid injection has antiinflammatory effects on tissues, dry needling can reduce pain by affecting substance P, beta-endorphin, and local blood flow levels
  • Dry needling has been shown to be effective against tendinitis
  • In this study, the most common adverse effects of dry needling were pain (38%) at the needling site and subcutaneous bleeding (12%).
    • Those were the unwanted effects of needling during the process and did not last very long

Reach out to your local providers to see if dry needling might be appropriate for your symptoms! Thanks for reading!! 

Threshold Physical Therapy and Performance #beatthecopay

ACL Reconstruction: What to use???

by OrthopedicsSport

Imagine… You’ve had a really bad day…

A friend called asking if you wanted to meet for a pick up game. It seemed like a good idea at the time! But, then you pivoted to intercept that pass, heard the knee ‘pop’, and collapsed in pain. The crazy bad swelling set in crazy fast. The physician at the urgent care place says it’s probably your ACL (anterior cruciate ligament) and you should schedule a consultation with an orthopedic surgeon, and (just maybe) they are progressive enough to also recommend some prehab with physical therapy to speed the recovery. 

So, you get home and decide to hop on Google to do a little research. Of course, the Google results diagnose you with death. It’s probably the black plague from your neighbors sickly pet…

Over the course of your research you decide to watch a youtube video on the ALC surgical procedure. You’ve had better ideas and now, not only does your knee feel sore and unstable, you’re feeling a little queasy. It is here that you realize that several types of tissue grafts can be used to reconstruct the ACL.

Wait. Wait. Wait. They are going to take a strip of tissue from somewhere else in your body to make your new ACL? Yep, it’s called an autograft and (more than likely) it’ll work out better than taking it from some dead individual (called an allograft), or a pig (yea, the domesticated omnivore). 

So, what can they take? What should they take? The optimal graft source remains a topic of controversy…

We’ve got the bone-patellar tendon-bone (BPTP), but there are well-documented issues including pain at the anterior/front of the knee, difficulty kneeling, increased incidence of mid- and long-term osteoarthritis, and possible kneecap fracture or rupture of the tendon. Yep, that last part is probably as bad as it sounds, but BPTP is an option on the table…

Then, we’ve got a hamstring tendon graft. Talk about a pain in the … well, you know. Again though, we’re seeing issues including weakness in hip extension and terminal knee flexion, higher infection rate, graft laxity (especially in females over time), and variable graft size and length. 

More recently, a graft from the quadriceps tendon (from the muscles at the front of the thigh down to the kneecap) has been looked at with serious potential. Even though it’s 2019, this method was advocated for back in 1979 and 1984. A recent ahead-of-print article in the American Journal of Sports Medicine published a systematic review looking at outcomes for quadriceps tendon vs bone-patellar tendon-bone, and hamstring-tendon autografts for ACL reconstruction. The good news – you have options!

What does the research say? In short, and when looking at the clinical and functional outcomes, the results for the quadriceps tendon were comparable to the hamstring tendon and bone-patellar tendon-bone. Additionally, the quadriceps autograft had less harvest site pain when compared to the bone-patellar tendon-bone, and better functional scores when compared to the hamstring-tendon graft. 

If we want to dive a little deeper into the literature findings from the review for quadriceps tendon ACL reconstruction:

  • Knee stability outcome and graft survival rates were comparable to patellar and hamstring tendon
  • Anterior knee pain was reported in only 6.1% of the cases
  • Graft failure (possibly worst case scenario) was shown in only 2.1% of the cases
  • Earlier return to activity and higher patient satisfaction
  • It doesn’t seem to be detrimental to the extensor mechanism with equivalent level muscle recovery at 1 year
  • Harvesting the central quadriceps free tendon leaves a stronger extensor mechanism when compared to harvesting of a patellar tendon graft 
  • Less analgesic consumption and less pain immediately postoperatively 
  • Earlier complete knee extension
  • Improved maturity of the graft at 6 months

The authors note some limitations in the study including differences in surgical techniques, quadriceps with or without bone block, hamstring with different muscular components and strand count, different fixation methods, and a lack of standardized rehabilitation protocols.

Despite the unfortunate injury, you’ll be on your game when you speak with the orthopedic surgeon discussing what might be best for you as an individual, and with regards to what is best functionally for recovery. Thanks for reading!

Threshold Physical Therapy and Performance Blood Flow Restriction

Blood Flow Restriction: Proximal, Distal, and Contralateral Effects

by OrthopedicsSport

Blood flow restriction (BFR) as been shown to promote greater increases in strength, hypertrophy, and endurance, when compared to low-load training alone, in healthy study subjects. Previously, significant gains have been shown in muscle fiber recruitment, hypertrophy, muscle circumference, and endurance. These then translated, functionally, into improvements in overall strength. Worth additional note, the technique has been shown to limit muscular atrophy that commonly occurs after an injury or surgery when considering a rehabilitation augmentation perspective. 

A recent 2019, ahead of print article in the multidisciplinary journal Sports Health, looked at the clinical efficacy of BFR training on muscle groups proximal, distal, and contralateral (non-BFR limb) to the tourniquet placement. Their study showed some interesting results…

First though, let’s consider what BFR training is, as well as how it is thought to be effective. BFR training typically consists of low-load exercises performed while wearing an inflatable tourniquet about the proximal aspect of the limb. This, as the authors note, results in partial restriction of the arterial flow and venous return which ultimately increases overall strength with effects similar to high-load training. It is thought that the increased metabolic stress from the restriction may upregulate various cellular signaling pathways in the hypoxic (decreased oxygen) environment resulting in adrenergic and hormonal changes resulting in muscular adaptation. These changes appear to include increased muscle protein synthesis, gene regulation of muscular satellite cells, fiber recruitment, hypertrophy, and endurance.

Interestingly the authors, Bowman et. al. (2019), reinforced much of the prior literature with regards to what has been previously found. Low-level BFR training produces substantially greater increases in strength both proximal and distal to the tourniquet placement. Also interesting, there were some changes contralaterally (at the non-BFR limb), but the authors note that a larger study cohort may be necessary to fully detect these smaller changes.

Worth noting, the most common complaints with BFR training are pain and discomfort which generally improve with treatment, and resolve when the treatment is stopped. A previous study also found complications including: bruising (13%), localized numbness or cold feeling (1.3%), light-headedness (0.28%), deep vein thrombosis (0.06%), pulmonary embolism (0.008%), rhabdomyolysis (0.008%), and worsening ischemic heart disease (0.02%).

If you’re looking to nerd out just a bit more on the science, some of the effects of BFR training include:

  • Improvements in aerobic exercise with increased stroke volume and VO2 max at a decreased heart rate
  • Hypertrophy of both types 1 and 2 skeletal muscle, as well as increased glycogen stores
  • Increases in growth hormone, cortisol, insulin-like growth factor 1, catecholamines, lactate dehydrogenase, nitric oxide synthase, vascular endothelial growth factor mRNA, hypoxia-inducible factor 1-alpha, and various heat shock proteins
  • Proliferation of myogenic stem cells

Blood flow restriction training continues to gain literary support in both the performance and rehabilitation arenas. Is it something that may be beneficial for you? Thanks for reading!

Threshold Physical Therapy and Performance Field Youth Concussion

Exercise As Medicine: Youth Concussion

by Sport

It has been found that individuals aged 14 to 25 years are disproportionately affected by concussion and, after suffering the injury, take longer to recover when compared to adults. A 2018 article, published in the Journal of Neurologic Physical Therapy, looked at some of the current concussion-related brain changes, recent research on the effects of exercise and physical activity, and the authors provide a potential progression after concussion.

The concussion injury results in a range of pathophysiological changes that may occur, and sets into motion a complex cascade of metabolic and neurochemical events. Additionally, it has been found that roughly 20% individuals who have suffered even one concussion present with persistent, clinically significant, physical and cognitive symptoms years afterwards. The diversity of external factors (location of injury, severity, and individual response), as well as the evolving secondary changes can result in unique and dramatic alterations in brain structure and function. For example, microscopic tears in the white matter of the brain and global changes in functional brain networks, where adolescence itself is a unique period of white matter development.

The current guidelines for returning to activity after a concussion injury include a brief period (about 3 days) of physical and cognitive rest. At the same time, appropriate exercise and activity levels continue to be supported in the literature for positive changes in brain neurophysiology. As an example, after moderate to severe brain injuries, fitness training has been shown to influence depression, physical symptoms, and self-reported health status positively. In fact, it is now recognized that prolonged rest (greater than 3 days) and activity restriction is not beneficial for recovery. Interestingly, although youth who have suffered a concussive injury do take longer to recover, there is no evidence that they require more time to rest. 

To support this, the authors noted both a retrospective and prospective study. In the retrospective, youth athletes who engaged in low to moderate physical activity and cognitive tasks experienced fewer symptoms and better neurocognitive test performance when compared to those who engaged in no physical activity as well as those who engaged in high levels of activity. Prospectively, youth with concussion who participated in moderate physical activity within 7 days of their injury had significantly fewer symptoms than those who were restricted. 

The authors proposed a progression of engagement, consistent with guidelines, for return to physical activity, exercise, and sport. They do note that it is a framework and would benefit from being experimentally tested, and should be used in conjunction with clinical judgement as well as consultation with the youth, family, and an interdisciplinary team.

Threshold Physical Therapy and Performance JNPT Screen Shot

It should also be noted that it is possible that vigorous exercise in the acute phase of recovery after concussion may be associated with disrupted brain dynamics and increased symptoms. Until more research is done, we don’t necessarily know the immediate and long-term neurophysiological responses of this type of exercise. 

We know that engagement in structured physical activity is a key element in concussion intervention. This follows the knowledge that there are clear benefits for neuroplasticity and recovery (brain health) after physical activity and exercise. Worth noting regarding youth concussion, implementation of exercise as daily therapy should involve a scheduled routine and incorporate peer networks for compliance. Additionally, and of significant importance, the activity after concussion should be limited to activities that do not put the individual at risk for another concussive injury. Also, encouraging social activities and allowing moderate use of social media can promote recovery and minimise the risk of post-concussive symptoms. 

Are you or someone you know recovering from a concussion? Working with your local physical therapist to find, and progress, appropriate levels of physical activity and exercise will be significantly beneficial! Thanks for reading!!