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Preventing Sports Injuries in the Unfit Individual
As a result of new Government health and exercise initiatives, large numbers of people with low fitness levels are likely to start arriving at sports centres, gyms and practices all over the country. This article reviews measures and advice for Sports Injury Prevention for clients returning to exercise after long periods of inactivity.
The Government White Paper The Government has recently announced its health promotion plans in its recent ‘Choosing Health’ White Paper, and outlines measures to get the UK population exercising their way back to fitness and health. One of the key issues on the White Paper’s agenda is obesity and related diseases, and it is easy to see why . Levels of obesity are forecast to rise to 25% of the UK population by 2010, and in 1998 alone the costs of obesity to the UK economy were estimated at
Since physical activity can help to prevent many conditions linked to obesity, the government intends to invest heavily in promoting exercise for health. Plans include a provision for state funded ‘Personal NHS Trainers’ drawn from the community to promote exercise regimens and a healthy lifestyle, in addition to the existing NHS Gym prescription scheme. As a result of this national health and exercise focus, the future prospects for Practitioners and Sports & Personal Fitness Trainers has never looked so rosy.
Safety & Good Practice Health Checks For Clients Returning to Exercise
Working with your local GPs If you have not already done so, make sure you take the time to establish good lines of communication with your local health practices now. Contacting local surgeries to agree ‘best practice’ for clients returning to exercise will minimise the risks of exacerbating any existing health problems and demonstrates professionalism. Establishing good links with local health providers can also help to generate referrals.
Pre-medical Any client who is seeking to take up regular exercise after a period of inactivity should seek a health check with their medical practitioner before they start any exercise programme. If there are underlying health problems such as high blood pressure, diabetes or musculo-skeletal problems these need detecting prior to starting an exercise regimen. Any individual with health problems can then return to exercise under the medical guidance and responsibility of their GP.
Walking and Swimming - A Gentle Start Exercise levels need to be built up gently to increase stamina for anyone who has been highly inactive for a long period. In some cases, encouraging walking or swimming for a few weeks before starting your training sessions may be best practice, and a build-up period for clients should precede any visits to the Gym or taking up of sports or aerobics. The pace and duration of exercise set during these activities should be enough to produce a gentle increase in heart and breathing rate, such that the individual should be able to hold a conversation without becoming breathless.
Walking If walking, clients need to ensure that the posture adopted is upright with head held high, relaxed arms, and movement from the hips not just the thighs or knees, preferably with short and quick steps.
Walking Guide
Preventing Injuries in the Gym and During Other Sports Taking the time to teach clients stretching and warm-up routines on their graduation to more strenuous exercise is vital to reduce the risks of sports injury. Providing counselling and advice sheets to clients will give them a handy reference and guide for when they are exercising alone.
In general terms, non-contact sport injuries are usually the result of poor technique such as ignoring advice to warm up, failure to use equipment properly, training errors or overuse injuries, all of which can be exacerbated by poor or inadequate nutrition.
The most common forms of preventable injuries arising from these causes are pulled muscles, joint damage, cramp, shin splints and muscle spasm.
Before Exercise - Warming up A proper warm up before any type of strenuous exercise is essential. Many of the body's tissues and especially muscle respond better to loading or stress when they are warm. The warming up process should include whole body exercise that increases blood flow to the muscles and makes then more responsive. Ideally, this should include jogging on the spot, cycling, or another low intensity form of exercise.
The length of this warm-up phase will depend upon the ambient temperature - the warmer it is, the less warm-up time is needed. However, the more vigorous the planned exercise the longer the required warm up phase. For example, warming up to sprint is not just a case of increasing temperature and local blood flow, but of gradually preparing the muscles and joints to generate maximum forces very quickly. Consequently, warming up for an exercise session may take as little as ten minutes, whilst warming up for demanding sports training can take 30 minutes or more. Therefore, the warm up period should be gradually extended as fitness returns and the intensity of exercise increases.
Avoiding Overuse Injuries and Excessive Stress Load on the Body Exercise inevitably produces stress on bones, joints, muscles and other tissues. In general terms, body tissues can withstand considerable stress as long as tissues have become accustomed to them. Injuries occur when the body has not adapted to the stress levels being placed on it; for example, jogging can produce forces that are three times body weight to go through the tissues, and sprinting or jumping requires the muscles to develop considerable levels of strength to power and control the physical actions required.
To avoid this form of injury, a carefully structured exercise programme tailored to individual fitness levels is vital to gradually build the necessary strengths. Individual training programmes should be carefully planned that include a gradual increase in exercise intensity, volume, duration, frequency and recovery times for optimal fitness without producing injury.
Choosing the right footwear Encouraging your clients to invest in appropriate footwear as well as choosing a suitable surface for exercise are extremely important to ensure the impact force going through the body is kept to a minimum. The ability of footwear to absorb shocks and provide stability and support characteristics will differ according to the sport, techniques to be used and individual body weight: therefore it is well worth advising your clients to buy footwear especifically designed for purpose.
Choosing the right environment for exercise Commencing exercise on hard or inappropriate surfaces are associated with overuse injury. Exercising on harder surfaces increases stress loading on the body and risk of overuse injury, and so people who take up jogging or tennis should be advised to commence on grass or softer surfaces wherever possible to build up strength before a transition to tarmac.
Also changing a clients training surface e.g. from grass to tarmac without making necessary changes to footwear or training patterns can cause injury. Therefore, any training pattern should allow for a gradual working in of the new equipment or environment. This will allow the body to work out precisely how to control the difference in stress loading and any changes in joint position that these modifications will have produced and adapt to them.
Technique A number of overuse injuries are clearly related to sports or exercise technique, and can arise from the repetitive use of a joint or muscle with a poor technique giving rise to excessive load on the tissues. For example, tennis elbow is usually an injury to an extensor tendon of the wrist, and may arise from an incorrect grip or swinging action whilst playing. In every case of overuse injury it is always worth considering whether the technique used is as good as it can be.
Furthermore, it should be remembered that skill breaks down with increasing fatigue, so care must be taken to ensure that the last period of any exercise is as technically correct as at the beginning, whether exercise takes place in the Gym or on a sports field.
Cooling Down & Stretching after Exercise Ensuring clients take time after exercise to gently cool down with approximately 10 minutes of gentle aerobic exercise followed by stretching will help to avoid cramps and muscle injuries. Many people do not realise that a stretch posture must be held for at least 40 seconds for any benefit to be gained. Stretching each major muscle group gently in turn can significantly help to reduce injury and muscle strains.
Keeping a Training Diary Regular reviews of clients performance and development along with keeping a training diary are essential to help to avoid injury from poor technique or an exercise overload. A training diary should include brief details of the session and activities, and this can help to identify what has changed in the training profile if an injury occurs, so that corrective action can be taken.
Paying Close Attention to Diet Many people who are overweight or return to exercise after a long period of inactivity may also have placed themselves on a calorie restricted diet. As a consequence, their diet may be nutritionally inadequate to support health adequately (especially with exercise) and so a basic nutritional assessment is good practice. Advice to modify diet, take supplements, sports drinks or other nutritional products should be provided as appropriate on review.
Increased mineral requirements Vigorous exercise places heavy demands on mineral levels - not only are the minerals calcium, magnesium, potassium and other salts lost during perspiration but during exercise the body will have a higher level of usage and demand for these minerals than a sedentary person. For example, Calcium and Magnesium are involved in cardiovascular function , nerve and muscle function , energy release and cellular hydration as well as being required to build and maintain bone mass. A poor diet combined with vigorous exercise can in itself be damaging, and there are several clinical studies that record a high incidence of osteoporosis and a loss of periods in women who exercise but follow poor dietary practices .
Ensuring that fruit and vegetable consumption reaches a minimum of 5 portions of fruit and vegetables daily along with at least four portions of calcium rich foods is essential for supporting health and a return to fitness. Encouraging appropriate use of a sports drink or mineral supplement can help to ensure that required mineralisation levels are achieved and maintained during and after exercise.
Increased amino acid requirements Whilst clients may be on a calorie restricted diet, their intake of meat and proteins providing a wide range of amino acids will be reduced. These nutrients are essential to help the conversion of fat into muscle, and a low calorie protein drink can provide an additional source of essential amino acids.
Increased stress on joints Clients who are overweight will already have increased stress on weight bearing joints, and will have a higher rate of cartilage wear than normal individuals. Numerous clinical studies have demonstrated that taking Glucosamine supplements (preferably with Chondroitin Sulphate, MSM and Manganese ) can help to support cartilage formation and repair and reduce the risks of joint injury as a consequence of exercise and overuse.
Supplemental Glucosamine has been traced to new cartilage formation within four hours of taking it.
Summary
Increasing numbers of unfit and overweight clients will be seeking help in response to national ‘health and exercise’ promotional campaigns. Ensuring that clients are properly equipped and trained to warm-up, cool down and stretch along with referral for a medical review and nutritional advice can greatly reduce the risk of sports injuries, and facilitate a trouble free return to health and fitness. Client Advice
Essential Do’s & Don’ts - Before Exercise
Essential Do’s & Don’ts - During Exercise
Essential Do’s & Don’ts - After Exercise
In the Event of Injury
2004 UK White Paper - Choosing Health
Osborne CG, McTyre RB, Dudek J, et al. Evidence for the relationship of calcium to blood pressure. Nutr Rev 1996;54:365-81.
Golf SW, Bohmer D, Nowacki PE. Is magnesium a limiting factor in competitive exercise? A summary of relevant scientific data. In: Golf S, Dralle D, Vecchiet L, eds. Magnesium 1993. London: John Libbey & Company, 1993:209-20.
Finstad EW, Newhouse IJ, Lukaski HC, et al. The effects of magnesium supplementation on exercise performance. Med Sci Sports Exerc 2001;33:493-8.
Drinkwater BL, Bruemmer B, Chestnut III CH. Menstrual history as a determinant of current bone density in young athletes. JAMA 1990;263:545-8.
Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad: the inter-relatedness of disordered eating, amenorrhea and osteoporosis. Clin Sports Med 1994;13:405-18.
McAlindon TE, LaValley MP, Gulin JP, Felson DT. Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA. 2000 Mar 15;283(11):1469-75.
Donohoe M. Efficacy of glucosamine and chondroitin for treatment of osteoarthritis. JAMA. 2000 Sep 13;284(10):1241; discussion 1242.
Leffler CT, Philippi AF, Leffler SG, Mosure JC, Kim PD. Glucosamine, chondroitin, and manganese ascorbate for degenerative joint disease of the knee or low back: a randomized, double-blind, placebo-controlled pilot study. Mil Med. 1999 Feb;164(2):85-91
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The Role For Osteopaths & Chiropractors in Monitoring Clients Nutrition & Bone Health
It is widely recognised that an adequate calcium intake is essential for the development of healthy bones and preserving and maintaining bone mass throughout adult life. For women, ensuring an adequate calcium intake is especially important: once women pass the menopause the rate of bone loss markedly accelerates. However, osteoporosis can affect all people and at all ages, and there are a range of different risk factors besides nutrition. These include a long term lack of weight bearing exercise, smoking, genetics and hormonal factors. Some medical conditions and treatments can also increase risks of developing Osteoporosis. Ensuring adequate dietary intakes of essential nutrients is a key preventative action that every adult can address easily, whether through diet alone or diet with supplementation, and in an integrated healthcare system client counselling is a key role that Osteopaths can fulfil. At present in the UK, one in three women and one in twelve men will have osteoporosis by the age of 50, and this situation is forecast to get worse over the next decade as the average age of the population increases. At present, the average calcium consumption of the adult population meets what is termed the Reference Nutrient Intake: the amount of calcium for 97.5% of the population to meet their nutritional requirements. This measure is currently set at 700 mg/day. However, this is an average, and a closer examination of the data from the UK National Diet & Nutrition Survey (2003) shows that a significant proportion of the population are not meeting this benchmark intake. (Tables 1 & 2) Of particular concern is the data for intakes in younger adults aged 18 - 24, whose nutritional requirements are higher and for whom bone mass is still accumulating. The implications for future incidence of osteoporosis or early-onset osteoporosis amongst this generation are very worrying. Furthermore, the literature suggests that the required intakes of calcium for Optimal Health are substantially higher. There is widespread disagreement between countries as to the precise amounts of calcium required in the diet for optimal health in adults. In the UK experts recommend 1200mg/day for those individuals deemed at particular risk of osteoporosis and 800 -1000mg/ day for all other adults from all sources, whether diet or supplements. In contrast however, The US recommendations are higher* Adults age 18 – 24 1200 – 1500 mg/day Men aged 25 – 65 1000 mg/day Women aged 25 – 50 1000 mg/day Women aged 50+ 1200 – 1500mg/day
* US National Consensus Panel of Experts Whichever measure of optimal calcium intake is used, it is clear that there is a need for many individuals to increase their calcium intake to take care of the health of their bones, irrespective of their age or sex. The mechanisms of calcium absorption, regulation and metabolism are dependent on a range of factors. Calcium is absorbed from the gut via two distinct and separate mechanisms, one active and one passive. The active transport mechanism is the one that is of primary importance, and calcium needs to be fully dissolved, ionised and separated from its carrier compound to be absorbed. Absorptive capacity is directly regulated by Vitamin D in its active form, which in turn is converted from the inactive to the active form by parathyroid hormone (PTH). When serum calcium levels drop, PTH levels become elevated increasing conversion of vitamin D to its active hormonal form, and promoting calcium resorption to elevate serum calcium levels. An increase in the active form of Vitamin D in turn increases calcium absorption form the gut. Because of the ability of Vitamin D to enhance calcium absorption, treatment protocols for supplementation advise increasing calcium intake in combination with an appropriate level of Vitamin D. Additionally, Magnesium plays a vital role in bone health as a Magnesium deficiency will result in hypocalcemia (low serum calcium levels) and low serum parathyroid hormone (PTH) and Vitamin D levels, as well as PTH and vitamin D resistance, which may serve as mechanisms for the development of osteoporosis.
Supplementation with Calcium and Vitamin D alone has been shown to increase bone mineral density and preserve bone mass in pre-menopausal women, and help to prevent excessive bone loss in women past the age of menopause. For this reason, supplementation is recommended where dietary intake is suspected to be insufficient for all adults, and should accompany any osteoporotic treatment for those diagnosed with the condition. Each dose of supplemental calcium should not exceed a maximum of 500mg, with 400mg as an optimal dose. Higher levels of calcium supplementation lead to excessively high serum calcium levels, promoting excess calcium excretion in the urine (hypercalcuria) and a lowering of serum magnesium levels. Additionally, although increasing calcium intake reduces risks for kidney stone formation, high doses of calcium supplements taken without appropriate levels of magnesium, Vitamin D along with an adequate fluid intake can increase the risk of kidney stone formation, rather than reduce it. As 400mg of calcium per dose is the optimal level that can be absorbed at one time without producing hypercalcuria, people who are suffering from or are at particularly high risk of osteoporosis and who would be advised to supplement with calcium at levels of 800mg/day or more should take their supplement in evenly divided doses, at least six hours apart. Whilst the data for the UK is limited, in the US, Italy and Europe osteoporosis and preventative treatment including supplementation and counselling occurs in only a small proportion of those at risk, including supplementation. Additionally, knowledge amongst younger age groups of their risks of osteoporosis if poor nutrition continues as well as steps that can be taken to prevent it are very low, and given current nutritional practices, this is a serious issue for the future health of their bones. Osteopaths can play an instrumental role in helping to prevent this epidemic by counselling clients on calcium nutrition, and where appropriate, recommending supplementation to help preserve bone mass and reduce osteoporosis risks.
Table 1: CALCIUM INTAKES: ADULT MEN
TABLE 2: CACLIUM INTAKES: WOMEN
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