Training & Conditioning 20.9 by Momentummedia

December 2010 Vol. XX, No. 9, $7.00

A Look at Exertional Rhabdomyolysis Strength Programs for Baseball Pitchers

Career Climb Becoming a head athletic trainer

Circle No. 100

December 2010, Vol. XX, No. 9

contents 34

15 Bulletin Board 5 New research on stretching and injury prevention ... Cranberry juice may fight staph infections … Division III to vote on strength coach supervision … Tracking the impact of big hits.

Comeback Athlete Allison & Kristen Chulada Bow (N.H.) High School

Sponsored Pages 12 Power Systems 19 Thera-Band/Performance Health 49 Fitness Anywhere Product News

51 State of the Industry 54 Therapy Technologies 58 Plyometrics 59 Product Launch 60 Topical Analgesics 60 More Products 56 Advertisers Directory

CEU Quiz 61 For NATA and NSCA Members

64 Next Stop: Web Site On the cover: Lindenwood University Head Football Athletic Trainer Tom Godar (far right) examines an athlete while Director of Athletic Training and cover story author Randy Biggerstaff looks on. Article begins on page 26. Photo by Don Adams Jr. TR AINING-CONDITIONING.COM

Treating the Athlete

Much Too Soon 15 Too The concept of “no pain, no gain” has become ingrained in athletic culture, but a serious condition called exertional rhabdomyolysis should have athletes and coaches on guard. By Dr. Stan Reents Optimum Performance

Power 20 Water Aquatic plyometrics give athletes the opportunity for an explosive workout with little impact. That means they can work harder for longer, with less risk for injury than on dry land. By Dr. Michael Miller & Dr. William Holcomb Leadership

26 Landing a job as a head athletic trainer takes more than experience Career Climb

and talent. It also requires strategically positioning yourself on the professional ladder. By Randy Biggerstaff Nutrition

Strength 34 Inner When it comes to bone health, there are many pieces to the puzzle. It’s likely your athletes are missing some of them in their everyday lives. By Michelle Rockwell Sport Specific

43 At Texas Christian University, pitchers are trained to be fast, powerful, Special Delivery

and explosive, while also taking into account rotational demands and individual imbalance issues. By Zach Dechant

T&C decemBER 2010

Editorial Board Marjorie Albohm, MS, ATC/L President, National Athletic Trainers’ Association Jon Almquist, ATC Specialist, Fairfax County (Va.) Pub. Schools Athletic Training Program Brian Awbrey, MD Dept. of Orthopaedic Surgery, Massachusetts General Hospital, and Instructor in Orthopaedics, Harvard Medical School Jim Berry, EdD, ATC, SCAT, NREMT Head Athletic Trainer, Myrtle Beach (S.C.) High School Leslie Bonci, MPH, RD Director, Sports Medicine Nutrition Program, University of Pittsburgh Medical Ctr. Health System Christine Bonci, MS, ATC Co-Director of Athletic Training/Sports Medicine, Intercollegiate Athletics, University of Texas Cynthia “Sam” Booth, ATC, PhD Manager, Outpatient Therapy and Sportsmedicine, MeritCare Health System Debra Brooks, CNMT, LMT, PhD CEO, Iowa NeuroMuscular Therapy Center Cindy Chang, MD Team Physician, University of California-Berkeley Dan Cipriani, PhD, PT Assistant Professor Dept. of Exercise and Nutritional Sciences, San Diego State University Gray Cook, MSPT, OCS, CSCS Clinic Director, Orthopedic & Sports Phys. Ther. Dunn, Cook, and Assoc. Keith D’Amelio, ATC, PES, CSCS Strength & Conditioning Coach for Men’s Basketball, Stanford University Bernie DePalma, MEd, PT, ATC Head Athletic Trainer/Phys. Therapist, Cornell University Lori Dewald, EdD, ATC, CHES, F-AAHE Department of Health Science, Kaplan University Jeff Dilts, Director, Business Development & Marketing, National Academy of Sports Medicine David Ellis, RD, LMNT, CSCS Sports Alliance, Inc. Boyd Epley, MEd, CSCS Director of Coaching Performance, National Strength & Conditioning Association Peter Friesen, ATC, NSCA-CPT, CSCS, CAT Head Athletic Trainer/ Cond. Coach, Carolina Hurricanes Lance Fujiwara, MEd, ATC, EMT Director of Sports Medicine, Virginia Military Institute Vern Gambetta, MA President, Gambetta Sports Training Systems P.J. Gardner, MS, ATC, CSCS, PES Athletic Trainer, Liberty High School, Colo.

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Joe Gieck, EdD, ATR, PT Director of Sports Medicine and Prof., Clinical Orthopaedic Surgery, University of Virginia (retired) Brian Goodstein, MS, ATC, CSCS, Head Athletic Trainer, DC United Gary Gray, PT, President, CEO, Functional Design Systems Maria Hutsick, MS, ATC/L, CSCS Head Athletic Trainer, Medfield (Mass.) High School Christopher Ingersoll, PhD, ATC, FACSM Director, Graduate Programs in Sports Medicine/Athletic Training University of Virginia Allan Johnson, MS, MSCC, CSCS Sports Performance Director Velocity Sports Performance Tim McClellan, MS, CSCS Director of Perf. Enhancement, Makeplays.com Center for Human Performance Michael Merk, MEd, CSCS Director of Health & Fitness, YMCA of Greater Cleveland Jenny Moshak, MS, ATC, CSCS Assistant A.D. for Sports Medicine, University of Tennessee Steve Myrland, CSCS Owner, Manager, Perf. Coach, Myrland Sports Training, LLC, Instructor and Consultant, University of Wisconsin Sports Medicine Mike Nitka, MS, CSCS Director of Human Performance, Muskego (Wis.) High School Bruno Pauletto, MS, CSCS President, Power Systems, Inc. Stephen M. Perle, DC, MS Professor of Clinical Sciences, University of Bridgeport College of Chiropractic Brian Roberts, MS, ATC, Director, Sport Performance & Rehab. Ctr. Ellyn Robinson, DPE, CSCS, CPT Assistant Professor, Exercise Science Program, Bridgewater State College Kent Scriber, EdD, ATC, PT Professor/Supervisor of Athletic Training, Ithaca College Chip Sigmon, CSCS Strength and Conditioning Coach, Carolina Medical Center Bonnie J. Siple, MS, ATC Coordinator, Athletic Training Education Program & Services, Slippery Rock University Chad Starkey, PhD, ATC Visiting Professor, Athletic Training Education Program, Ohio University Ralph Stephens, LMT, NCTMB Sports Massage Therapist, Ralph Stephens Seminars Fred Tedeschi, ATC Head Athletic Trainer, Chicago Bulls Terrence Todd, PhD, Co-Director, Todd-McLean Physical Culture Collection, Dept. of Kinesiology & Health Ed., University of Texas-Austin

December 2010 Vol. XX, No. 9 Publisher Mark Goldberg Editorial Staff Eleanor Frankel, Director Abigail Funk, Managing Editor R.J. Anderson, Kenny Berkowitz, Patrick Bohn, Mike Phelps, Dennis Read Circulation Staff David Dubin, Director Sandra Earle Art Direction Message Brand Advertising Production Staff Maria Bise, Director Neal Betts, Natalie Couch, Trish Landsparger Business Manager Pennie Small Special Projects Dave Wohlhueter Administrative Assistant Sharon Barbell Advertising Materials Coordinator Mike Townsend Marketing Director Sheryl Shaffer Advertising Sales Associates Diedra Harkenrider (607) 257-6970, ext. 24 Pat Wertman (607) 257-6970, ext. 21 T&C editorial/business offices: 31 Dutch Mill Road Ithaca, NY 14850 (607) 257-6970 Fax: (607) 257-7328 info@MomentumMedia.com Training & Conditioning (ISSN 1058-3548) is published monthly except in January and February, May and June, and July and August, which are bimonthly issues, for a total of nine times a year, by MAG, Inc., 31 Dutch Mill Rd., Ithaca, NY 14850. T&C is distributed without charge to qualified professionals involved with competitive athletes. The subscription rate is $24 for one year and $48 for two years in the United States, and $30 for one year and $60 for two years in Canada. The single copy price is $7. Copyright© 2010 by MAG, Inc. All rights reserved. Text may not be reproduced in any manner, in whole or in part, without the permission of the publisher. Unsolicited materials will not be returned unless accompanied by a self-addressed, stamped envelope. Periodicals postage paid at Ithaca, N.Y. and additional mailing offices. POSTMASTER: Send address changes to Training & Conditioning, P.O. Box 4806, Ithaca, NY 14852-4806. Printed in the U.S.A.

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Bulletin

Board To Stretch or Not? In the long-running debate over whether there are benefits to stretching before exercise, compelling new information has been introduced. A study by USA Track and Field (USATF) analyzed data from nearly 1,400 runners and discovered that there was no statistically significant difference in injury risk between those who stretched before running and those who did not. The study, published on the USATF Web site, involved runners age 13 and up and took place over three months. Runners were assigned to one of two groups: stretchers and non-stretchers. The stretching group was given written and photographic instruction on proper technique and told to complete a three- to five-minute routine that involved stretching their quads, hamstrings, and gastrocnemicus/soleus muscle groups immediately prior to running. Runners assigned to the non-stretching group were instructed to begin their workouts without limbering up. Over the three months, both groups saw runners suffer injuries that prevented them from running for at least three days at a rate of 16 percent. The rates of injury preventing running for more than a week and more than two weeks were also identical. The findings were both meaningful and surprising to those involved. “I had gone into this thinking that stretching would prevent injuries,” Dan Pereles, MD, a Washington, D.C.-area orthopaedic surgeon who led the study, told The New York Times. “I was fairly sure of it. Instead, static stretching has no particular benefit.” Researchers did find that runners who regularly stretched before the study began and were assigned to the non-stretching group had a disproportionately high injury rate. Malachy McHugh, PhD, Director of Research at the Nicholas Institute of Sports Medicine and Athletic Trauma in New York City told the Times that it was likely due to the change in pre-run preparation and is not proof that the stretching itself was beneficial. “Your body adapts to its routine, and if that routine is monotonously habitual as with many runners, it doesn’t take much of a change to cause injury,” he said. For more information about the USATF study, go to: www.usatf.org/stretchstudy/index.asp.

Cranberry Juice May Stop Staph New research from the Worcester Polytechnic Institute shows that cranberry juice may have previously unidentified bacteria-fighting powers. Cranberry juice has already been shown to help guard against urinary tract infections, but it may also protect against some forms of Staphylococcus aureus. TR AINING-CONDITIONING.COM

Researchers had 20 healthy female students drink either 16 ounces of cranberry juice or a placebo, and then provide urine samples after two, eight, 24, and 48 hours. The samples were incubated for 24 hours with strains of E. coli or Staphylococcus aureus, and then tested for the presence of biofilm. Biofilm results when a sufficient number of cells—in this case bacteria—grow together as a colony. The greater the biofilm mass, the more likely there will be an infection. The samples from participants who drank the cranberry juice had significantly less biofilm formation than those from the control group. “The results we saw with Staphylococcus aureus were dramatic,” says Terri Camesano, PhD, lead author of the study and Professor of Chemical Engineering at WPI. “Essentially, we saw no biofilm growth at all.” Camesano, who presented the findings at the national meeting of the American Chemical Society in August, says preventing the formation of biofilms is critical because they are a precursor to infection. The biofilms provide a protective environment for the bacteria—one that can be difficult for the immune system to break up. Preventing the formation of the biofilm makes it easier for the body to rid itself of bacteria naturally. The authors didn’t draw any conclusions as to why cranberry juice is effective against the formation of biofilms, or offer suggestions on whether athletes should increase their consumption. They also don’t know yet if cranberry juice might help in blocking methicillin-resistant Staphylococcus aureus– better known as MRSA. But Camesano says more research is planned. “Understanding what’s happening with the Staph results is an important new area to examine,” Camesano says. “While I would prefer not to speculate on the reasons behind the results, we are planning to expand our research.”

More Strength Coach Interaction in D-III? At the NCAA Convention in January, Division III members will vote on a proposal that would allow strength coaches to conduct and monitor voluntary off-season workouts for athletes. The proposal was submitted by the Minnesota Intercollegiate Athletic Conference, and Executive Director Daniel McKane says it would allow athletes to improve their performance and reduce their risk of injury. “Our members feel the off-season is when our athletes really need and want input on how to improve their strength and conditioning,” he says. “Current NCAA Division III rules restrict the level of interaction athletic department personnel can have with athletes during the off-season. We want to provide our athletes the education they’re asking for. “The rule change should also prevent in-season injuries,” McKane continues. “We know that if athletes are in better shape they’re going to suffer fewer injuries.” T&C decEMBER 2010

Bulletin

Board Current Division III rules allow strength and conditioning staff members to observe off-season workouts for safety issues only—they cannot offer coaching advice to athletes. But McKane says he’s not positive all coaches know the rules. “I think some of them believe strength coaches are allowed to do more than they actually can, so we’re inconsistent across the division,” he says. “Changing the rule would allow for a more consistent interpretation.” The Division III Student-Athlete Advisory Committee (SAAC) expressed concerns that athletes would feel more pressure to attend voluntary workouts if the proposal passes. “Since the coach can also be the one doing the workouts, there’s more pressure on the student-athletes to participate, even though it is voluntary,” Rowan University SAAC member Brittany Petrella told The NCAA News. Questions about the proposal can be addressed to Daniel McKane at: dpmckane@miac-online.org.

The Impact of Impacts There has been much attention paid recently to the danger of concussions in football. Now, researchers are looking at the effects hard hits can have on other areas of the body, too.

This season, selected members of the NFL’s San Francisco 49ers are wearing pressure sensors inside their equipment, which measure the impact of blocks and tackles. Offensive players have sensors in pads on their chests and abdomen area, while defensive players have them in their shoulder pads. Sensors include wireless transmitters, which send collision information to researchers’ computers on the sideline. Daniel Garza, MD, an emergency and sports medicine physician at Stanford Hospital and Clinics and the 49ers Medical Director, said in a press release that the aim of the research is to help athletic trainers better understand football-specific injuries. “We’re trying to understand the biomechanics of the trauma players receive, so we can assess how well their body armor is working and what physicians should be looking out for,” he said. “It’s difficult to assess these athletes on the sideline when they’ve potentially sustained some kind of internal injury, especially when they’re reluctant to leave the game.” Ultimately, researchers hope their findings lead to advances in protective equipment and earlier diagnoses of injuries. Though the project is focusing on the NFL, the findings should help players at any level according to William Maloney, MD, Professor and Chair of Stanford’s Department of Orthopaedic Surgery and a 49ers team physician. “The benefit of [the knowledge] is that we can translate the care of high-level athletes to everyday athletes,” he said in a press release. n

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ComebackAthlete

Allison and Kristen Chulada Bow (N.H.) High School By R.J. Anderson

The Chulada family comeback centers around a pair of identical twins: Allison, who was born with a congenital heart defect, and Kristen, who developed an unusual eating disorder as a high school junior. At first glance, it’s two different stories about two different girls. But dig deeper and you’ll discover the conflicts overcome by a mother and father who were forced to balance on a tightrope strung between their personal lives and professional backgrounds. As medical professionals, both parents felt their backgrounds were perfectly suited to help their children work through their adversities, especially in Kristen’s case. However, as they quickly found out, it’s not always a perfect scenario for mom and dad to serve as vehicles for delivering expert, but hard to hear advice. And it’s not always easy to treat your own children. Born in 1993, Allison, the older of the twins, was immediately diagnosed with tetralogy of Fallot, a rare condition found in five out of 10,000 infants. A combination of four different heart defects, tetralogy of Fallot is marked by: a large ventricular septal defect (VSD), pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. While her sister was sent home with a clean bill of health, Allison spent four weeks in a neonatal intensive care unit before leaving the hospital. Then at the age of one, she underwent open heart surgery to relieve the right ventricular outflow tract stenosis and repair the VSD. The surgery was deemed a success and Allison went on to have a very happy, healthy childhood. Each year, she was evaluated by a cardiologist, and each year she passed all physical tests with flying colors. However, Cliff and Debbie were warned early on that follow-up valve replacement surgery awaited most tetralogy 8

T&C DECEMBER 2010

Jane Strablizky

Most medical professionals try to avoid bringing their work home with them. But for Cliff Chulada, MS, LAT, ATC, CAPE, Athletic Trainer at Bow (N.H.) High School, and his wife Debbie Chulada, RD, LD, a Clinical Dietitian at Merrimack County Nursing Home in Boscawen, N.H., that has not been possible. When very different—but very serious—medical situations afflicted their teenage daughters, their family lives and careers came crashing into one another.

Field hockey players and twin sisters Allison (right) and Kristen Chulada led Bow (N.H.) High School to the state finals this fall, while their father, Head Athletic Trainer Cliff Chulada, oversaw their unique comebacks. of Fallot patients. “But we didn’t know if that was for sure,” Cliff says. “And we certainly didn’t know when.” Just before the start of her sixth grade year on the afternoon following the first day of tryouts for her middle school’s field hockey team, Allison went to her annual follow up appointment with Thomas Johnson, MD, a cardiologist at the Dartmouth-Hitchcock Medical Center. “The doctor told us not only did she have to stop playing field hockey, but she’d probably need to have open heart surgery within the next couple of years,” says Cliff. “That was a shock. We hadn’t noticed any symptoms when she was home or out playing sports.” The exam, which included an echocardiogram and a stress test, revealed that Allison’s heart had right ventricle hypertrophy and pulmonary regurgitation. She would not be R.J. Anderson is an Assistant Editor at Training & Conditioning. He can be reached at: rja@MomentumMedia.com. TR AINING-CONDITIONING.COM

ComebackAthlete allowed to participate in any activity with cardiovascular demands. Allison was devastated. “She was moving into middle school and her sister and all of their friends played sports, so it had a big impact on her socially,” Cliff says. “Eventually, she found new activities and new people to hang out with.” During the fall of her seventh grade year, testing revealed increasing ventricle hypertrophy and pulmonary valve leakage. The following summer, Allison underwent open heart surgery to have the valve replaced. She spent the rest of the summer restricted from all physical activity and wasn’t allowed to lift anything heavier than 10 pounds for six months. By spring, she was cleared to play in goal for a youth lacrosse team—and she jumped at the chance. She helped her team win a championship, but after two years of very limited physical activity, Allison’s athletic development was well behind that of her peers. Meanwhile, as Allison struggled, Kristen was making her mark as a standout field hockey and lacrosse player. And her sister’s situation was not lost on Kristen, who recognized and appreciated the opportunities she was afforded. “Kristen was disappointed and upset about Allison’s situation,” Cliff says. “But I think she used Allison’s limitations as motivation for herself and took nothing for granted. Her attitude was, ‘Even though you can’t do things, I’m lucky enough to be able do them, so I’m going to work extra hard and make you proud.’” Then, the summer before their freshman year at Bow High School, Allison received some very good news. After a number of issue-free follow up appointments, she was cleared for a full return to activity with no restrictions. Right away, Allison had her sights set on making the j.v. field hockey team that fall. But to do so, Cliff knew she would need to greatly improve her entire athletic package—from strength and conditioning to skill work. Though part of his job is to design strength and conditioning programs for many of the teams at Bow, Cliff recognized he had to tread lightly when it came to prescribing exercises for Allison. “I knew it wouldn’t work if her dad told her she would have to do this or do that to improve,” he says. “So I only supplied workout suggestions on stuff like interval training. Kristen and Allison picked it up from there and worked together. Kristen pushed Allison and that was much better than me doing the pushing.” The twins’ hard work paid off as Allison made the j.v. squad while Kristen was one of just two freshmen to be selected for the varsity field hockey team. Throughout the season, Cliff kept a close eye on Allison. “I worked with her coaches throughout her freshman year,” he says. “I would phrase it like, ‘Here’s what I think will be effective’ and also asked them to watch Allison very carefully to make sure she wasn’t overdoing it.” As expected, Allison’s biggest hurdle was overcoming her lack of endurance, much of which could be attributed to the structural limitations of her heart. “They made a number of changes to her heart during surgery, including closing a defect between the ventricles and expanding her pulmonary TR AINING-CONDITIONING.COM

artery, so there’s obviously scarring in those areas,” Cliff says. “Even now as a senior, she still doesn’t have the same stamina that other kids do and she has to work pretty hard to maintain the level she’s at. “But she still gets excited when she sees improvement,” he adds. “Just the other day, they were doing a team run and she was excited to come in eighth place and felt better than she ever had.” After a successful freshman campaign, Allison came back stronger as a sophomore and was named captain of the j.v. team. The next year, with her conditioning and skills improving at a steady clip, Allison moved up to the varsity field hockey team, joining Kristen, who was named a team captain. At that point, things were looking great for the Chulada family. However, the good feelings would soon wane. That fall, as the field hockey team finished a successful playoff run, Kristen made a conscious decision to transform her diet by cutting out unhealthy junk food and snacks. At first her parents didn’t think it was too big of a deal, but

“We thought that because we are professionals, we could just intervene and everything would be okay pretty quickly ... But we weren't taking into account Kristen's psyche at that point.” Kristen then began to take things too far. “She started cutting more and more foods from her diet,” Cliff says. “It’s not that she wouldn’t eat, it’s just that there were fewer things she would allow herself to eat. Unfortunately, unbeknownst to us at the time, she had a shrinking definition of what was considered healthy food.” With the arrival of winter, the Chulada family’s schedules became even busier and Kristen’s limited eating went unnoticed. “Kristen competes in Nordic skiing, which is held off campus, and I spend a lot of evenings covering basketball and other sports,” explains Cliff. “So my wife and I would often make dinner and leave it for the girls to heat up and eat when they got home. It turns out Kristen was not eating what we had left for her, but only foods she chose herself.” A typical day’s worth of nutritional fuel would consist of a protein bar and a bowl of cereal. Sometimes Kristen would go through an entire day eating only a piece of fruit. At 5-foot-4 and already a slim 100 pounds, Kristen began losing more and more weight. “But it being winter in New Hampshire, we were bundled up in clothes all the time, and we didn’t really notice her weight change,” Cliff says. Her body deprived of calories, Kristen’s skiing performance took a turn for the worse. Honored as Bow’s breakout skier as a sophomore, Kristen’s junior season was full of setbacks. She wasn’t finishing as strongly as she had the year before and athletes she previously bested were now finishing ahead of her. While her skiing performance was a sign something was T&C DECEMBER 2010

ComebackAthlete amiss, it was her food mannerisms that eventually made her parents suspicious. For example, Kristen would cut her food into small pieces and eat very slowly, wouldn’t sit down for meals, and would only eat foods that she prepared—all classic indicators of an eating disorder. “As my wife and I started recognizing those signs, we thought that because we are professionals, we could just intervene and everything would be okay pretty quickly,” says Cliff, who is also a teacher in Bow’s health education program and covers nutrition as part of his curriculum. “Well, it didn’t work out quite as easily as we had anticipated.” As winter turned into spring and Kristen traded in her skis for a lacrosse stick, the disordered eating continued. Despite her parents’ best attempts at intervention, which included trying to add supplemental food and shakes, by late April, Kristen had dropped to 89 pounds with a body mass index of 16 and body fat percentage of about five percent. Friends and relatives could clearly see there was a problem and her ability to play lacrosse was noticeably diminished. “Even though Debbie and I are both medical professionals, we were unprepared to deal with the significant psychological aspects of this disorder in our own child,” Cliff says. “Because my wife works in geriatric nutrition and sees many patients who need to put weight on, she had a very clear view of what we needed to do. She would say, ‘We can just give her these foods and she’ll

Kristen was removed from all physical activity, and she started to see real progress. Though she was frustrated at not being allowed to play sports with her friends, by July she was back over 100 pounds. gain weight.’ But we weren’t taking into account Kristen’s psyche at that point.” By late May, their intervention efforts proved ineffective, and the Chuladas knew it was time to seek outside help. They found Marcia Herrin, RD, founder of the Dartmouth College Eating Disorders Prevention, Education and Treatment Program, who has significant experience in treating eating disorders in adolescents. Herrin found Kristen's symptoms to be typical of orthorexia, an uncommon disorder that describes people who have developed a fixation with healthy eating or a fear of unhealthy foods. The obsession for healthy foods can result from a number of factors, including family eating habits, societal trends, a recent illness, or even just hearing something negative about a food type or group in the media. Evaluation in hand, Herrin and the Chuladas added two more healthcare professionals to their team—a mental health professional and a pediatrician—both of whom specialize in treating eating disorders. As the physician, Nancy Turkington, MD, of Montshire Pediatrics in Hanover, N.H., monitored Kristen’s overall health. She found Kristen’s low 10

T&C DECEMBER 2010

heart rate and blood pressure severe enough to warrant hospitalization. But the Chuladas instead opted to pursue aggressive outpatient treatment utilizing the Maudsley Approach, which stresses family-based treatment. A big part of the Maudsley Approach is including the entire family in meetings and treatment. Initially, each week, Kristen and at least one of her parents met twice with Herrin and once with Turkington. And each week Kristen would meet alone with Ruth Elliott, LICSW, a therapist and social worker based in Concord, N.H., to vent her feelings about everything from her treatment and food issues to school and her home life. Another part of the Maudsley Approach is having someone supervise the patient’s meal consumption during the day. This took a strong effort from the entire family. “It became a day-to-day good cop-bad cop routine between my wife and me,” explains Cliff. “Some days my wife would have to be the one who was a little more firm and I would be the one who was a little more supportive, and other days our roles were reversed. “Allison, on the other hand, was more of a watchdog,” he adds. “She supported Kristen in her eating and encouraged her to eat with us or eat where she could be seen. She kept an eye on what her sister was doing. And Allison did it without being adversarial at any point—she wasn’t a snitch, but simply kept us informed about whether Kristen was meeting her goals.” Overall, Herrin gave the Chuladas a simple goal: Quickly add pounds to Kristen’s frame by any means necessary. This caught Debbie a little off guard. “At first, it was frustrating for my wife as a dietician, because Herrin wasn’t totally concerned about incorporating macronutrient balance or vitamin and mineral intake. It was simply about figuring out what foods Kristen would eat and working with those foods to develop a plan,” says Cliff. “So if there was a day when ice cream made up a chunk of the calories, that was okay because it was all about getting calories.” As treatment progressed, Herrin measured Kristen’s weight for a given week and made small modifications to the plan based on how she was progressing. That might mean adding an extra snack after a meal that Kristen would have to eat. Cliff says one of the keys to success was focusing initially on the foods Kristen wasn’t afraid of, then slowly sprinkling in foods that she was hesitant to eat. “For example, Kristen had gotten it into her mind that she would not eat French toast even though it was one of her favorite foods,” Cliff says. “The challenge would be that between now and her next visit, she needed to eat a piece of French toast. We also focused on the weight gain—striving for a pound or a pound and a half in one week.” Kristen started treatment in late May and was allowed to finish the last two weeks of the lacrosse season so she would put up less of a fight. “The one caveat was that she could only play if she stopped losing weight,” Cliff says. Once lacrosse was over, Kristen was removed from all physical activity, and she started to see real progress. TR AINING-CONDITIONING.COM

ComebackAthlete Though she was frustrated at not being allowed to play sports with her friends, by July she was back over 100 pounds. At that point, Kristen was cleared to play in half of a summer field hockey game once per week. If she continued to gain weight during this period of added activity, she would be allowed to play even more minutes. By August, Kristen was cleared to participate in conditioning drills three days per week in preparation for field hockey preseason. However, in order to be eligible to practice and play in preseason, Herrin and Turkington told Kristen she needed to weigh at least 105 pounds—a mark she hit a week before the first practice. Throughout the fall, Kristen improved her weight to 109 pounds, and had a great senior campaign. Playing alongside Allison, whose first career varsity goal propelled the team into the state championship game, Kristen notched a team-high 20 goals and led the Falcons to an undefeated regular season and runner-up state champ status. Though Cliff is extremely proud of what his daughter has overcome, he’s quick to note that she is by no means out of the woods. “There are a lot of statistics about the relapse of an eating disorder, and when she’s left to her own devices next year at college, that’s something we’re going to have to track with the rehab team,” he says. “There’s a feeling that we’ve done a good job and gotten her to a safe place, but

that doesn’t mean this is beaten yet.” With both daughters back on track, Cliff says the key to making each situation work for him was to check his professional ego at the door. “Initially, I spent too long trying to figure out how I could use my training to intervene, but ultimately, I had to recognize that more specialized care was needed,” he says. “Then it was all about letting the special-

“I learned I needed to emphasize my role as a parent over that of an athletic trainer ... I found I needed to take a step back and not damage the relationship by pushing them in ways you can with other athletes.” ists do their jobs and supporting their decisions and opinions as much as I could. “In each instance, I learned I needed to emphasize my role as a parent over that of an athletic trainer,” he adds. “Sure, my wife and I both knew what had to be done, especially in Kristen’s case, but as parents it was very difficult to communicate that in a way that worked. As an athletic trainer, I found I needed to take a step back and not damage the relationship by pushing them in ways you can with other athletes.” n

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Circle No. 106

equipment solutions

PowerForce™ Free Standing The next-generation PowerForce free standing bag is here! Designed for kicking and punching without the need for hanging. The removable foam collar increases or decreases pivoting of the bag from its heavyduty rubber coil. Fill the 33.5" diameter base with water or sand for stability. The 77" overall height and 16.5" diameter striking surface allows for any size user. Bag and collar covered in smooth durable fabric backed with nylon canvas and open cell padding. 2 piece base holds up to 280lbs. of water.

Jab

• Stand in a staggered stancewith knees slightly bent and hands up. • The punch arm matches the foot that is forward • Forcefully rotate at the hips and knees extend the arm and punch forward • Recoil, reset and repeat for the desired number of punches • Repeat from the opposite side

Start

Finish

Cross

Start

• Stand in a staggered stance with knees slightly bent and hands up • The punch arm is the opposite of the foot that is forward • Forcefully rotate the hips and knees and extend the arm and punch forward • Recoil, reset and repeat for the desired number of punches • Repeat from the opposite side

Finish

Hook

Start

• Stand in a staggered stance with knees slightly bent and hands up. • The punch arm matches the foot that is forward • The punch arm should be flexed at approximately 90 degrees and shoulder level • Forcefully rotate the hips and knees and drive the fist into the side of the bag • Recoil, reset and repeat for the desired number of punches • Repeat from the opposite side

Finish

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Combo Punches

• Stand in a staggered stance with knees slightly bent and hands up. • The combo is jab, cross, and hook • Forcefully rotate the hips and knees and drive the fist into the side of the bag • Recoil, reset and repeat for the desired number of punches • Repeat from the opposite side

Cross

Jab

Hook

Low Kick

Start

• Stand in a staggered stance with knees slightly bent and punch ready position • Rotate at the hips lifting the back leg off the floor and extend the leg to kick the target at a low level • Hit the target with the top of the foot and shin bone • Recoil, reset and repeat for the desired number of kicks • Repeat from the opposite side

Finish

Mid Kick

Start

• Stand in a staggered stance with knees slightly bent and punch ready position • Rotate at the hips lifting the back leg off the floor and extend the leg to kick the target at hip level • Hit the target with the top of the foot and shin bone • Recoil, reset and repeat for the desired number of kicks • Repeat from the opposite side

Finish

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TREATING THE ATHLETE

TOO MUCH

TOO SOON

The concept of “no pain, no gain” has become ingrained in athletic culture, but a serious condition called exertional rhabdomyolysis should have athletes and coaches on guard. By Dr. Stan Reents

n mid-August, the McMinville (Ore.) High School football team was the center of a flurry of national news reports. It would have been nice if the media coverage was about the team’s upcoming season or a star player. But instead, reports said many athletes on the squad had been stricken with some sort of mysterious illness. According to an Oregon Public Health Division preliminary report, over the course of three days, about half of the 43 players who attended a training camp before the start of official practices went to a local hospital complaining of severe muscle pain in their arms. At first, it was assumed the athletes had misused a creatine supplement, but days later a different theory emerged: the players were suffering from exertional (or “exercise-induced”) rhabdomyolysis (ER). According to the report, the athletes had undergone a short, repetitive triceps workout—the main cause for the

Stan Reents, PharmD, is the Editor in Chief of AthleteInMe.com® and author of Sport and Exercise Pharmacology. A member of the American College of Sports Medicine, he holds Personal Trainer and Lifestyle Counselor certifications from the American Council on Exercise and is a United States Tennis Association certified coach. He can be reached at: Editor@athleteinme.com. TR AINING-CONDITIONING.COM

getty images

T&C DECEMber 2010

TREATING THE ATHLETE condition. Other factors that likely contributed included a hot environment— one media outlet stated the workout was held indoors in a 100-plus degree room—and undetected dehydration. Of the 22 players with ER symptoms, three underwent emergency surgery for compartment syndrome, 12 were hospitalized for treatment of ER, and all made a full recovery. In a nutshell, ER is the extensive breakdown of skeletal muscle that can

occurs in trained runners after a marathon, even though their post-race CK levels exceed 3,000 U/L. There is a race in Greece called the Spartathlon that requires running from Athens to Sparta (152 miles!) in under 36 hours. Within 15 minutes after completing the event, participants’ CK levels are sky high, though very few require medical attention during or after the race. This phenomenon is called asymptomatic rhabdomyolysis.

Exertional rhabdomyolysis symptoms generally last a couple of days, after which muscle pain subsides and creatine kinase levels return to normal. But in severe cases, there may be irreversible muscle damage. lead to kidney failure and even death. During any challenging workout, muscle damage is expected—we stress our muscles, they break down, then build back up stronger than they were to meet the demands of the stress placed on them. But when that process occurs at a massive rate, some bodies can’t always handle the processes necessary for recovery. While considered to be uncommon, people of any age or fitness level can be stricken with ER. The condition most commonly occurs in “crushing” injuries, such as those experienced in earthquakes or car accidents, where muscles are severely damaged by impact, but athletes can and do fall victim to ER. Fortunately, with early and proper treatment, athletes who develop ER can make a complete recovery. ER Explained When muscle cells break down, the damaged contents leak out and are deposited into the bloodstream. Two of the products released are the enzyme creatine kinase (CK) and the muscle protein myoglobin. The kidneys can only handle a certain amount of protein, so when too much myoglobin reaches the kidneys, it can result in kidney damage and even complete failure. The elevated levels of CK are what help physicians diagnose ER. While the normal range of CK levels is 60 to 320 units per liter (U/L) of blood, in severe cases of ER, CK levels can reach above 300,000 U/L. It’s important to note, however, that elevated CK levels don’t always mean the athlete is experiencing ER. For example, it rarely 16

T&C DECEMber 2010

Because the runners who participate in the Spartathlon, and ultra marathoners everywhere, train their bodies to become accustomed to this sort of prolonged demanding activity, their fitness levels are so elite that less muscle trauma occurs and ER symptoms do not occur. ER follows a progression. Within hours of muscle breakdown, CK and myoglobin levels become elevated. Though CK levels can only be determined with a blood test, when a person has too much myoglobin in their blood-

ER symptoms generally last a couple of days, after which muscle pain subsides and CK levels return to normal. But in severe cases, there may be irreversible muscle damage. If this happens, an athlete can lose muscle strength and range of motion that may never return. ER has also been shown to cause compartment syndrome, a painful condition that includes intense pressure on nerves, blood vessels, and muscles in an enclosed area (compartment) of the body and generally requires surgery to relieve pressure. WHAT CAUSES ER? As implied by its name, exertion is the most important risk factor for ER. For someone with a low activity level, all it may take is a challenging workout session for symptoms to appear. And even in a well-conditioned athlete, higher than normal stress on the muscles can put them at risk for ER. But coaches conduct tough workouts all the time. How can someone know how much is too much? There is no simple answer, but the key is if the athlete’s body is accustomed to a particular workout. In published cases, the following workout examples led to ER: • A 22-year-old college senior whose exercise routine included running three to five miles per day and lifting

Eccentric exercises, when the muscle lengthens, have been shown to cause more muscle injuries than concentric exercises, when the muscle contracts. In one case, a 40-year-old male developed ER in his biceps after doing several sets of negative curls. stream, their urine turns a dark brown color—a symptom commonly referred to as “Coca-Cola urine.” Within 24 to 48 hours of the workout, ER sufferers experience severe, even incapacitating muscle pain, swelling, and profound weakness in the overworked area of the body. For example, if an athlete were to perform an intense biceps workout and it triggered ER, the athlete would feel pain only in their arms. If there’s any sign of ER, the athlete must seek medical help immediately—at an urgent care facility or an emergency room. IV fluids are often necessary, as rehydration is an important component for recovery. If treatment is not sought, kidney damage can result several days later.

weights five days per week developed ER after her fitness trainer increased her weight lifting load and reps in one session. The trainer pushed her to continue the workout and had to assist her from one exercise machine to the next as her legs shook noticeably during the session. Forty-eight hours later, the emergency room found her CK value was 234,000 U/L. • A 29-year-old man developed ER after starting a new abdominal workout: 30 to 40 sit-ups per day for five consecutive days. • A former Navy sailor and wrestler was put through a three-round workout of dumbbell thrusters, air squats, and burpees at a gym and claims the resultTR AINING-CONDITIONING.COM

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TREATING THE ATHLETE ing severe bout of ER left him permanently disabled. He sued the gym and was awarded a settlement in 2008. The type of exercise may be another risk factor. Eccentric exercises, in which the muscle lengthens, have been shown to cause more muscle injuries than concentric exercises, in which the muscle contracts. The more muscle damage there is, the higher the risk of ER. In one case, a 40-year-old male developed ER in his biceps after doing

mined that she had CPT II deficiency. Hot weather and dehydration may also contribute to an athlete developing ER. Though there is no scientific evidence to support that a hot environment contributes to the onset of ER, in many documented cases, the workout room temperature or outside humidity has been unusually high. It’s possible that certain drugs could put someone at higher risk for ER. Published case reports point to

The first episode occurred following a five-hour tournament when she developed severe muscle soreness. The athlete was unable to straighten her elbows and knees ... Though her urine turned a brownish color, she did not seek medical attention. several sets of negative curls—in which a spotter assists in lifting a barbell up to the ready position and then the subject lowers the barbell on his own until his arms are in an extended position. Roughly 18 hours after doing negative curls, this athlete experienced severe biceps pain and could not fully extend his arms. Some people may be at higher risk due to genetic predisposition. For example, people with carnitine palmitoyltransferase (CPT) II deficiency, an inherited metabolic disorder, have a higher likelihood of developing ER. This was the case for a 19-year-old college freshman who experienced two episodes of ER while playing competitive ultimate Frisbee. The first episode occurred following a five-hour tournament (her actual playing time was estimated to be three hours) when she developed severe muscle soreness. The athlete was unable to straighten her elbows and knees and had difficulty standing because of soreness in her back. Though her urine turned a brownish color, she did not seek medical attention. After muscle soreness resolved in three days, she continued her normal activity level. But two weeks later, she had a relapse when she participated in a two-hour Frisbee scrimmage followed by a two-hour karate class. Shortly thereafter, she experienced severe muscle cramping and this time sought medical attention. The following day, her CK levels peaked at 59,000 U/L. Although the athlete had no history of ER and had been active all her life, it was subsequently deter18

T&C DECEMber 2010

two categories of prescription drugs: phenothiazine-type neuroleptics (antipsychotics) and statins (cholesterollowering drugs). Anabolic steroids have also been blamed for the development of ER in bodybuilders, though this is not proven. Unfortunately, it’s not possible to predict which patients taking these drugs will develop ER, but it’s important to be aware of the increased risk.

to an already-instituted workout program is best. For athletes who take the summer off, resuming training with intense two-a-day preseason sessions can be dangerous. Coaches should encourage their athletes to stay active when school is out of session. Keeping athletes’ core temperatures as close to normal as possible will also help. Hydration plays a key role in keeping core temperatures under control and allowing an athlete’s body to perform physical tasks in a healthy way. Wearing breathable clothing and not performing intense workouts in extreme heat are other suggestions. And although research is lacking regarding ephedra’s link to ER, it would be best to steer clear of any supplements with ephedra in them. Ephedra can cause problems because it may increase core body temperature and/or may allow the athlete to train harder than is safe. If it’s not already a ritual for them, athletes should consider adding a postworkout recovery beverage to their routine. Several recent studies have shown that post-exercise CK levels are lower in athletes who regularly consume a sports drink that contains protein.

Sport coaches, strength coaches, fitness trainers, and athletes all need to better understand that training gains can still be achieved by “moderately” challenging the muscle group. Pushing the athlete to his or her limits isn’t always the best approach. Ephedra, its closely-related replacement synephrine, and creatine have made the list as possible contributors, too. In one case, a healthy 21-year-old soldier developed ER after a physical fitness test, and admitted to taking two tablets of an herbal supplement containing ephedra daily for a month leading up to the test. The evidence that says creatine supplementation could be at fault for ER is far less substantial. Still, many researchers hypothesize that it could contribute to increased risk. PREVENTION PROGRAM The guidelines for preventing ER are very similar to general advice for anyone beginning a new workout routine. Because the main culprit is doing too much at once, gradually moving into a workout program or a gradual increase

The human body talks to us all the time. When a muscle group is shaking or no longer able to contract, that’s a major signal to stop activity. In fact, at this point, muscle damage may have already occurred. The concept of “no pain, no gain” should be discouraged. Sport coaches, strength coaches, fitness trainers, and athletes all need to better understand that training gains can still be achieved by “moderately” challenging the muscle group. Pushing the athlete past his or her limits isn’t always the best approach and certainly isn’t worth the risk. n

To view full references for this article, go to: www.TrainingConditioning.com/References. TR AINING-CONDITIONING.COM

Improving Your Athlete’s Range of Motion By Phil Page, PhD, PT, ATC, CSCS

Contract-relax stretching is one of the most effective forms of stretching for increasing flexibility, yet most stretching devices on the market focus only on static stretching. Studies show that prestretch contraction is more effective at increasing range of motion compared to a static stretch. The Thera-Band® Stretch Strap is a revolutionary alternative to static stretching straps. Unlike a static-only stretch strap, the TheraBand Stretch Strap can be used for both contract-relax and static stretches. The Stretch Strap’s innovative elastic, multi-loop design allows for more comfortable stretching of major muscle groups. The numbered loops on the strap provide visual feedback for the athlete and allow the athletic trainer or therapist to provide clear, accurate

instruction when setting goals and limitations. Studies indicate that dynamic stretching can actually enhance performance in jumping and running while static stretching may decrease their performance. Runners, tennis players and basketball players should not rely on static stretching, but instead incorporate dynamic stretching into their warm-up. Here are just three of the many stretches you can perform with the Thera-Band stretch strap that you can use to enhance your athlete’s range of motion and flexibility. Each Thera-Band Stretch Strap comes packaged with fullyillustrated instructions for 15 exercises.

Thera-Band Stretch Strap General Instructions – Breathe in as you contract the muscle and breathe out as you relax and stretch. Use the numbered marks to illustrate proper placement and to demonstrate progressions. Each exercise has three phases: 1. Start Phase – - Begin with moderate tension in the strap

2. Contract Phase – - Provide enough elasticity in the strap to support resistance during muscle contraction. - The muscle should be at resting length (mid-range) or slightly elongated - Contract the muscle through the range of motion or hold a static contraction for 3 to 5 seconds

Gastroc

Rectus Femoris

3. Stretch Phase – - Provide enough tension in the strap to elongate the muscle - Hold the stretch for 10 seconds - Repeat 5 times or as instructed

Hamstrings

Start: Begin by lying prone with one end of the strap secured to your foot and your knee bent. Grasp the other end of the strap in your hand over your shoulder.

Start: Sit with knee extended and back straight. Place the middle of the strap around your foot and grasp the ends at your waist.

Start: Begin by lying on your back with one knee bent. Place opposite foot in the loop at one end of the strap and grasp the other end of the strap with your hands at your chest.

Contract: Push your foot downward against the strap, keeping your knee straight. Maintain your hand position. Stretch: Breathe out as you pull the straps toward you into dorsiflexion, stretching your calf muscle.

Stretch: Breathe out as you pull the strap and leg toward your head, stretching your posterior thigh.

Contract: Push your foot against the strap, extending your knee. Maintain your hand position.

Stretch: Breathe out as you pull the strap over your shoulder, stretching your thigh as you bend your knee, allowing your knee to bend.

Contract: Keeping your knee straight, push your leg downward, extending your hip against the strap.

Dr. Phil Page directs the Thera-Band Academy. He is a licensed physical therapist and certified athletic trainer. His clinical and research interests include the role of muscle imbalance in musculoskeletal pain, and in promoting physical activity in older adults. He has presented internationally on exercise and rehabilitation topics, and has numerous publications. He has a master’s degree in Exercise Physiology, and a PhD in Kinesiology. He is also a certified strength and conditioning specialist. He has worked with the athletic programs at LSU, Tulane, the New Orleans Saints and Seattle Seahawks, as well as the United States Olympic Track and Field Trials.

Recognized worldwide as the industry standard, Thera-Band offers progressive products for strength, balance, and flexibility that are referenced in over 1,000 published articles and abstracts. For more information about this product or any other Thera-Band products, visit www.Thera-Band.com or call (800) 321-2135.

Water Power W Optimum performance

By Dr. Michael miller & Dr. William Holcomb hen you think about plyometric exercises, you likely picture at h letes bou nd i ng across a field, hopping over cones and hurdles, or jumping on and off plyo boxes. You probably don’t visualize any of the exercises being performed in a pool, but that may soon change as aquatic plyometrics continues to grow in popularity among athletes. Because the work has decidedly less impact in the water than on dry land, athletes don’t need as many restrictions on the number of foot touches they can perform in a given week. Aquatic plyos also decrease concerns about acute injury, and pool work provides a nice change of pace by adding more variety to workouts. During our careers, we have both used aquatic plyos with private clients and athletes of all ages, and have taught the method to students and colleagues for many years. We’ve seen increases in agility and overall total body strength with minimal muscle soreness for the athletes. We have also found that our athletes and clients really look forward to these pool workouts and quickly master the exercises so they can do them on their own.

©getty images 20

T&C december 2010

Aquatic plyometrics give athletes the opportunity for an explosive workout with little impact. That means they can work harder for longer, with less risk for injury than on dry land.

Michael Miller, EdD, ATC, CSCS, is a Professor and Director of the Post Professional Graduate Athletic Training Program at Western Michigan University. He can be reached at: michael.g.miller@ wmich.edu. William Holcomb, PhD, ATC, CSCS*D, FNSCA, is an Associate Professor at the University of NevadaLas Vegas. He can be reached at: bill.holcomb@unlv.edu. TR AINING-CONDITIONING.COM

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Circle No. 109

Optimum performance WHY WATER? When an athlete’s performance goal is to develop explosiveness, plyometrics in general are a great tool to help them achieve it. Dry-land plyos have been shown to increase acceleration, power, vertical jump height, and leg strength, all while increasing athletes’ joint awareness and overall proprioception. The same has now been proven with the use of aquatic plyos. Any power-based movement consists of an eccentric muscle action, an amortization phase, and a concentric contraction. The elastic energy stored

during the eccentric action provides the force needed for the concentric portion of the movement. The goal of training with plyometrics is to shorten the amortization phase—to train muscles to more rapidly load and contract. This allows the movement to be completed in a shorter amount of time, thus leading to increased power and explosiveness. One drawback to performing plyometric exercises on dry land lies in the intensity of the movements. Impact forces are relatively high, so too many foot touches can result in muscle soreness and increased risk for injury. When plyos are

performed in water, however, the impact forces are greatly reduced. And strength gain opportunities are not negatively affected because viscosity and drag provide resistance, forcing athletes to work hard through the movements. The decreases in impact forces are largely due to the fluid density and buoyancy of the water. Buoyancy acts as a counterforce to gravity, so in waistdeep water, body weight is supported during the eccentric portion of a lowerbody plyometric movement, significantly reducing impact. One study found as much as 54 percent of a person’s body

SIX-WEEK PROGRAM Below is a list of aquatic plyometrics activities you can use with your athletes two to three times a week. These exercises follow a standard progression in terms of volume and intensity and are best conducted in waist-deep water. When compared to a typical dry land plyos program, foot contacts are doubled in water, so more work can be performed in a shorter amount of time while achieving similar results. Lateral cone hop

Week One

3x10

Side-to-side ankle hop

2x15

Tuck jump

Standing jump and reach

2x15

Wall pushup

3x12

Wall sit-up

3x15

Front cone hop

6x5

4x6

Week Five

Week Two Side-to-side ankle hop

2x15

Single-leg bound with aqua gloves

2x10

Standing long jump

2x15

Box jump (18 inches)

2x10

Lateral jump over barrier Double-leg hop

6x5 10x3

Double-leg hop with aqua gloves Lateral cone hop

2x12

Tuck jump Week Three

6x5

Lateral jump over barrier

3x10

Side-to-side ankle hop

2x12

Wall push-up

3x15

Standing long jump

2x12

Wall sit-up

4x20

Lateral jump over barrier Wall push-up Double-leg hop Lateral cone hop

6x4 2x10 8x3 2x12

Week Six Box jump (18 inches)

4x5

Double-leg hop with aqua gloves

6x3

Single-leg bound with aqua gloves

2x12

Tuck jump

Standing long jump with fins

3x10

Single-leg lateral jump

Lateral jump over barrier

T&C december 2010

2x10

Depth jump Single-leg lateral cone hop

Week Four

6x3

2x10 4x5 2x10

8x4

TR AINING-CONDITIONING.COM

Optimum performance weight is supported by water when submerged to the waist. Because water reduces impact, athletes with joint, muscle, or tendon pathologies who cannot withstand forces on land can participate in aquatic plyometrics without precipitating more harm. For the same reason, aquatic plyometrics can be particularly beneficial for heavier athletes in sports like football. For athletes without joint problems who can effectively perform dry-land plyos without issue, switching to aquatic plyos can help prevent the onset of pain and reduce recovery time. These athletes can see even greater strength gains because the number of foot touches, as well as drop height, don’t need to be as severely restricted as in dry-land plyos training. Adding water to a plyo program also enhances joint awareness and proprioception by providing a sensory awareness that cannot be matched on land. The sensation of water against the skin allows athletes to be more mentally and physically aware of where their body parts are and how they are moving. This is especially true as they are moving through the water since athletes can

feel their limbs and body placement during activity. With aquatic plyometric training, results may be seen in as little as three to four weeks for untrained athletes and about six to eight weeks in highly trained athletes. Of course, the rate of improve-

mended. One of the great advantages to aquatic plyos is that athletes can generally progress more quickly to higher volume and training intensity. We’ve also found that aquatic plyometrics produce minimal post-workout soreness when compared to dry-land plyometrics.

Because of the added element of higher cardiac output in water, we usually have our athletes measure their own heart rate several times during the workout to gauge intensity and make sure we’re not pushing them too hard. ment will be based upon the intensity and frequency of the workout program. DEVELOPING A PROGRAM All you need to start aquatic plyometrics is a pool and a block of time two to three days per week over a six- to 12-week period. Most collegiate and high school athletic programs have relatively easy access to a lap or therapeutic pool or a nearby community facility that does. When developing any plyometric program, gradual increases throughout the training period is generally recom-

For example, in a 2010 study, researchers compared subjects who performed plyometrics programs either on dry land or in a pool. Even when the volume of plyos was doubled, participants in the aquatic plyos program reported minimal muscle soreness when compared to their dry-land training counterparts. It’s important to note that athletes’ heart rates should be monitored during these sessions to help gauge intensity. When athletes are submerged in water, even waist deep, their cardiac output in-

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Circle No. 111 T&C december 2010

Optimum performance creases due to the hydrostatic pressure effects on the baroreceptors and atrial stretch receptors. In turn, this increases stroke volume. It has been suggested in previous studies that athletes perform aquatic plyo work at an intensity that is roughly 16 to 17 beats per minute lower than their standard heart rate during other highintensity activities. Because of the added element of higher cardiac output in water, we usually have our athletes measure their own heart rate several times during the workout to gauge intensity and make sure we’re not pushing them too hard. While water can help decrease impact forces, the resistive forces and density make initial movements more difficult to perform correctly, so during initial plyometric training, more emphasis on the instruction of movements is required. After athletes adapt to moving in the water and controlling their body position, less supervision is needed. However, the more athletes you have in the water at one time, the more difficulty there will be in properly supervising them. While there are no specific 217-431_ExScience_3.4x4.8_4C:Layout guidelines for aquatic plyometrics, our

experience says that a group of 15 athletes is the limit for one supervisor. To prevent slipping on the bottom of the pool surface and to minimize extraneous drag on the body, athletes may find that shoes made for the aquatic environment and form fitting swim trunks work best. While there is no required equipment for a plyos program, aquatic boxes and cones are often used. Aquatic boxes are specialized submersible boxes that not only stay on the pool bottom but can be incrementally heightened, and have surfaces that help stop slippage. Traditional plastic cones can be used as barriers to jump toward or over, but must be weighted to remain on the pool bottom. We recommend using cones with plastic weights (one- to two-pound dumbbells will suffice) affixed by thin ropes or other non-metal fasteners. The weights can be inserted inside the cones to the tip and will not affect their overall stability. The cones should also have holes to allow water through and diminish the buoyancy effect. Since they are relatively light, bumping one will not cause physical harm to the athlete. 1 Training 1/8/10 sessions 11:10 AM 1 can Page last anywhere

from 20 to 45 minutes, not including warmup. Our typical five- to 10-minute warmup includes walking in neck-deep water the circumference of the pool (or just the shallow areas) along with lunges, high-knee lifts, high-heel lifts, and cross country ski movements in shallower water. WATER FACTORS Although aquatic plyos use the same general movements and exercises as dry-land plyos, you cannot simply take your existing dry-land plyos program and add water. For one thing, because more work will be required by the athlete to overcome the initial inertia and resistance of the water, the distance or height of jumps or barriers may need to be shorter or lower. For example, jumps that are spaced three to four feet apart on land may need to be two feet apart (or less) in the water. Second, variations in water level need to be factored in, since they will contribute to alteration of movement and overall intensity of the exercises. Based on personal experiences, we suggest most bounding or hopping activities be

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Optimum performance performed with the arms and hands fully above the water. If the arms swing into and through the water, the drag and resistance force obstructs the normal rhythm of the movement. In addition, doing plyos in chest- or neck-deep water can be very difficult for people being introduced to aquatic plyos for the first time, and an athlete’s focus may tend to move toward performing the movements correctly, taking away from the main goal: decreasing the amortization phase of explosive movement. While a bit uncomfortable at first, athletes quickly adapt to moving with their arms out of the water. The height and weight of athletes should also be considered. For example, in a 42-inch deep pool, a tall athlete may have water up to the waist while a shorter athlete may be in chest-deep. In addition to height, a lighter athlete—one who weighs 100 pounds, for instance—will tend to “float” more during movements when compared to a heavier athlete, making the movement easier for them. To compensate, the distance or height of the jumps can be altered or you can station different height or weight groups in shallower or deeper areas of the pool. Another aquatic-specific factor when bounding or hopping across the length of the pool is water drag. For example, in a line of seven athletes following one another single-file across the pool, the first athlete is forced to overcome more water resistance than the last person, who will most likely just get pulled along by the current. In these instances, alternating direction of movement will limit the amount of current and ensure that nobody gets a free ride. Some of the lower-body exercises we’ve found to be effective include two-footed hops over a cone, lateral jumps over a barrier or cone, and standing long jumps in which the athlete jumps as high and as far forward as possible. When a barrier or cone is involved in the exercise, make sure the athlete is actually going over it and not inadvertently around it. We start with 18-inche barriers, and as athletes progress, incrementally increase the height up to 25 inches. While most aquatic plyometric programs focus on lower extremity exercises, upper-body plyometric movements can be conducted in the pool, too. For example, angled push-ups with hands on the wall utilize the drag property of water. And for core strengthening, when athletes float on their back or chest on the surface, water helps them stay afloat but also encourages them to use their core muscles to remain in the correct posture during the movement. As your athletes are ready for more advanced work, you can add upper-body resistance to any of the lower-body exercises you are already performing by having them work in chest- or neck-deep water with their hands underwater. To make these movements more difficult for athletes, have them wear aqua gloves or fins over their hands to create more surface area and impede movement. (When starting out, however, we advise sticking with hands above the water.) Water offers a new and different training environment that works as a motivational stimulus for athletes and increases the potential to improve performance quickly. Athletes can become bored with their routines sin the weightroom or even outdoors, so why not have them jump in for not only a great workout but some fun, too? n

To view full references for this article, go to: www.Training-Conditioning.com/References. TR AINING-CONDITIONING.COM

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Author Randy Biggerstaff (center), Director of Athletic Training at Lindenwood University, has helped many assistant athletic trainers move to head jobs throughout his career. He is currently mentoring Tom Godar (right), who explains his own strategy for career advancement on page 30.

DON ADAMS JR.

LEADERSHIP

Career Climb Landing a job as a head athletic trainer takes more than experience and talent. It also requires strategically positioning yourself on the professional ladder.

By Randy Biggerstaff

t an NATA Convention several years ago, many of us heard an inspirational and exciting talk by Robin Roberts about her success as a television broadcaster. When asked how she advanced in her career, she said, “I put myself in a position for good things to happen to me.” When assistant athletic trainers ask me what they need to do to become a head athletic trainer at the college level, I have a similar answer: Put yourself in a position for growth and to be noticed. Moving up in the athletic training profession doesn’t happen only through hard work, and it doesn’t happen overnight. It takes strategic planning and initiative. There are three major areas to concentrate on when trying to position yourself for a head athletic training job—education, experience, and networking. By focusing on these three avenues, which often intertwine, you’ll show potential employers that you have what it takes to lead a department.

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EDUCATION Education is found in two areas: formal and continuing education. Formal refers to your degrees in athletic training or related fields. If you are reading this magazine, you likely have already secured your undergraduate degree. If you have not earned your master’s degree yet, this is a great place to start positioning yourself. Before you choose a master’s program, put a lot of thought into where you want to be a head athletic trainer, then apply to graduate programs that fit your plan. If your dream is to head a large NCAA Division I athletic program—and take on the pressure that accompanies it—you’ll want to get your master’s at a big-time school. If you think a smaller college is a good fit, then look at those types of programs. If you’re not sure, pick an institution that is different than the school where you received your undergraduate degree or where you are currently working so you can experience a different setting. You should also find a program that

provides many internship options. Continuing education is another important method you can use to position yourself. We all need to get our CEUs every year, but continuing education can do more than simply keep us certified. If you make the most of continuing education opportunities, you can open doors and advance yourself in significant ways. One is to use your CEUs to form a specialty, which shows a future hiring committee that you have initiative and passion for the field. When I graduated from college, I saw a real need for athletic trainers who could take care of chronic injuries in the lower leg. (This was in the 1970s when the marathon craze was beginning.) So I made the effort to attend every workshop and semiRandy Biggerstaff, MS, ATC, is Director of Athletic Training at Lindenwood University. He was inducted into the NATA Hall of Fame in June and was honored as the NAIA Head Athletic Trainer of the Year in 2007. He can be reached at: rbiggerstaff@lindenwood.edu. T&C DECember 2010

LEADERSHIP nar I could find on this topic area. I was a high school athletic trainer at the time and worked closely with the school’s track and field team to test my newly acquired knowledge. A second way to use CEUs is to increase your knowledge base. When I was a new athletic trainer, I felt a lack of expertise in a lot of areas so I attended the NATA Convention each year and went to every seminar possible. The key is to take advantage of any chance for learning that you come across. Finally, choose continuing education opportunities that also allow you to net-

athletic trainer, you must have previously worked with an NCAA Division I football team. From my own career, I can tell you how important it is to have comparable experiences. I worked in the clinical setting for 20 years and then found myself the head athletic trainer and program director here at Lindenwood, an NAIA school with 20 sports. As I readied myself for my first two-a-days in 20 years that summer, I had severe butterflies in my stomach and night fears weeks beforehand. I did fine once the job began, but I was truly afraid of failure. It

If you are interested in being a head athletic trainer at a small college, you may be asked to teach. Therefore, becoming involved with academic committees is important. Look for openings both on your campus and within NATA education or curriculum groups. work. In other words, do not only look at course content but also the possible attendees. And frequent those seminars that allow interaction with the presenters and other attendees. EXPERIENCE When a hiring committee is reviewing resumes, they are usually poring over a huge pile. To narrow it down, the first thing they look for is a “good fit,” which means someone who has worked at a school that is similar to their own. Especially at the higher levels of collegiate sports, becoming a head athletic trainer requires experience in that setting. It is rare for an NCAA Division I institution to select candidates from other divisions to interview. Therefore, make sure your positions as an assistant athletic trainer are at institutions similar to your dream head athletic training job. If you are an assistant at a large school and feel that a head job in the same setting is unsatisfactory for your quality of life, look for an assistant job at a small school so you can get experience in that setting. Another point to consider is that a Division I school with football usually wants its newly hired head athletic trainer to serve as its head football athletic trainer. This does not mean you have to be the head football athletic trainer forever, but you will be expected to fill that position for several years. So, if your goal is to be an NCAA Division I head 28

T&C DECember 2010

would have been a much easier transition if I had worked at another NAIA or small NCAA school previously. It can also help to ask yourself, “What’s missing from my experiences?” Covering football, basketball, and baseball might show that you have been trusted with high-profile sports, but do you have any experience with soccer and track and field? Or maybe your resume lacks coverage of women’s teams. What question marks might pop up for someone reviewing your resume? To fill in any gaps, consider volunteer work. Local professional sports teams are often looking for athletic trainers to help during the summer and with home games during the season. You can contact your state athletic trainers’ association about working at high school championships. And there are always local sporting events that need sports medicine coverage. These volunteer opportunities also allow you to meet other athletic trainers in your area, which helps with your professional networking. Internships are another great way to get experience you don’t already have. If you have summers off, that is a perfect time to intern somewhere. Even if you work during the summer, you can sometimes set up internships on a limited basis (like during a one-week vacation or on summer evenings) while still holding down your current job. Many professional football and baseball teams

provide spring and summer internships, and the USA Olympic training centers offer two-week internships throughout the year. Finally, it’s advantageous to have some practice with the administrative side of the job. Being a head athletic trainer involves duties like supervising a staff, budgeting, and negotiating with others. To gain experience, ask your head athletic trainer if you can assist in these areas. Even if he or she can only delegate small portions of the administrative work to you, it can provide you with insight into that part of the job. You can also gain some administrative know-how by working on committees. This includes local, state, or national athletic training groups, campus committees, or even local volunteer boards, like a Rotary club or a nonprofit health center. Along with being involved in discussions about administrative and leadership issues, such work shows a hiring committee you understand the importance of giving back to your community and know how to get along with people in other professions. If you are interested in being a head athletic trainer at a small college with a curriculum program, you may be asked to teach. Therefore, becoming involved with academic committees is important. Look for openings both on your campus and within NATA education or curriculum groups. One more idea for gaining administrative and leadership experience is to volunteer to sponsor the athletic training student organization on your campus. And if your school does not have such a group, go ahead and start one! NETWORKING There is one area that can trump all the education and experiences you may pile up: networking. The people you come into contact with both professionally and otherwise (volunteering, committee work, and so on) can have a tremendous effect on you landing a head athletic trainer position. I mentioned earlier that I was offered my current position at Lindenwood even though my professional experiences did not include working at a small college. I owe that to networking, which put me in front of the right people at the right time. About 20 years ago, when I was a clinical athletic trainer, an orthopedic surgeon I had worked with donated the TR AINING-CONDITIONING.COM

LEADERSHIP money to replace the turf in the stadium at Lindenwood. He asked if I would chair a committee charged with bringing activities to the stadium to raise revenue so the field could be maintained. This chair came with a seat on one of the advisory boards of the college. I also volunteered to help the school’s head athletic trainer with coverage when he had a conflict or needed to be absent. A few years later, the head athletic trainer at Lindenwood decided to pursue a position as a head athletic trainer at one of the larger high schools in the area. I called the president of the college and asked if he might be interested in letting my clinic provide athletic services for its teams. The president stated that he was not interested in contracting out our services but instead wanted to know if I was interested in becoming the university’s head athletic trainer. Because people at the school knew me, I was offered a job that has turned out to be fantastic. Their interactions with me were ultimately more important than my lack of experience as an athletic trainer at the small college level. Having a professional network can also get your resume examined by those who matter more closely. When a busy athletic director is in the process of reviewing candidates for the school’s open head athletic training job, he or she is probably scanning the pile of resumes pretty quickly. If the athletic director gets a call from someone they respect—maybe a former assistant athletic trainer at the school who is now a head athletic trainer elsewhere—who says, “I think this candidate has what it takes,” it makes a huge difference. The athletic director will read your resume and cover letter carefully, with positive thoughts in the back of his or her mind. How do you build your network? Start by understanding that every contact you make can reap rewards many years down the road. From your first day as an undergraduate to the day you retire, you will meet athletes, coaches, students, professors, administrators, and fellow athletic training students who will have an impact on you. The volleyball athlete you are rehabbing right now could be an assistant athletic director at a school where you apply to be head athletic trainer five years from now. Professionally, there are many additional avenues you can pursue to build TR AINING-CONDITIONING.COM

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LEADERSHIP

Getting in Position At Lindenwood University, author Randy Biggerstaff is currently mentoring one of his assistants, Tom Godar, MS, ATC, who serves as Head Football Athletic Trainer and Associate Professor, to become a head athletic trainer. We asked Godar about his game plan for moving up the ladder. T&C: Why do you want to become a head athletic trainer? Godar: After developing my skills and confidence as an assistant for nearly 10 years, I have a lot of faith in my ability to contribute at a higher level. I am especially excited to continue working in a small college setting, where I can both teach future athletic trainers and work with motivated student-athletes on a daily basis. How are you making sure you have the right experiences? Early in my career, I was given the opportunity to teach classes, volunteer at several state and national events, and assume various administrative roles within the university. I also made sure to get experience with football while in graduate school—with a little luck and some networking, I was hired as the Head Athletic Trainer for an indoor professional football team and then as an athletic training intern with the St. Louis Rams. As I’ve taken on new challenges, I’ve always understood the importance of being properly prepared, and I’ve tried to learn from every mistake. I never settle for a partial understanding of anything, and I allow my natural curiosity to help me develop. I’ve come to understand the importance of taking advantage of every opportunity to gain a better understanding of all areas within the athletic training profession. Have you used continuing education to grow? With advancements made on a daily basis in the fields of medicine, exercise science, rehabilitation, and modalities, I know I have to continually expand my current knowledge. I’ve used state, district, and national conventions and seminars to meet with others, discuss current trends, and learn new concepts. How are you learning about the administrative side of becoming a head athletic trainer? I’ve learned by taking advantage of opportunities, asking questions, and having a strong desire to be involved. I’ve taken on tasks like meeting a prospective student and his or her parents, conducting a thorough inventory, and developing a budget. It’s about stepping up and being willing to accept new roles, tasks, and challenges.

T&C DECember 2010

DON ADAMS JR.

Lindenwood University Head Football Athletic Trainer Tom Godar (right) talks with Biggerstaff, who has given him more oversight of the athletic training staff at Lindenwood. Godar says the experience has helped him better understand the role of a supervisor. I really appreciate that Randy has also given me opportunities in supervision and delegation of responsibility. It is critical that a good supervisor has the necessary confidence, trust, and personality to assign various tasks to others and ensure the completion of all jobs—and these characteristics can take some time to develop. Through these experiences, I now understand how difficult the role of a supervisor and administrator can be and the importance of keeping the entire staff positively motivated. Have you gotten involved in outside committees? I haven’t and this is a future goal of mine. As I’m still working on establishing myself in my current position, it’s been tough to find extra time for outside committees. I hope to do this in the near future. — Eleanor Frankel

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LEADERSHIP your network. Every continuing education course you attend and volunteer opportunity you take on is a chance for networking. The most valuable event to attend is the NATA Convention. There is no profession that has more members in its professional organization and most of the members attend the national meeting once every three years. This means you will cross paths with every head athletic trainer in the country at least once every three years. Can you imagine having all those athletic trainers as part of your network? The possibilities are immense. I have attended every NATA Convention since I graduated from college, and I have been involved in discussion at one time or another with Pinky Newell, Spike Dixon, Otho Davis, and most of the present and past presidents. This does not mean I am a part of their inner network, but I think I could call them to ask about a job they posted. And there are many athletic trainers I see at the convention that I get to know and trust more and more with each passing year. When a job is posted, I could certainly contact them and ask if they

happen to know anyone at the school or have any inside information, which is what can land that initial interview. The network also sometimes provides you with advance notice of jobs, which is becoming more and more important to getting your foot in the door.

fessors, you need to work with them. A recommendation, even a mediocre one, is better than a poor one or no recommendation at all. And if you have made mistakes in the past, try to rectify them. Maybe you were headstrong as a student and got in argu-

One last part of networking is finding a great mentor who can help you with your career path ... Choose someone who you respect and can talk easily withâ&#x20AC;&#x201D;you need to be able to take constructive criticism from them. Itâ&#x20AC;&#x2122;s just as critical to not have a negative network. There are examples of athletic trainers who, after 20 years of experience, still have job applications derailed by their head athletic trainer from their college years. The old saying â&#x20AC;&#x153;do not burn any bridgesâ&#x20AC;? is still very appropriate in this day and age. On the day they start in our program, I remind every student that the staff and I will someday be writing letters of recommendation for them. What do they want that letter to say? Even if you donâ&#x20AC;&#x2122;t like your supervisors or pro-

ments with professors and staff members. It is a great sign of your maturity to contact them and let them know you have changed. You can even apologize and thank them for their guidance that you now better understand and appreciate. One last part of networking is finding a great mentor who can help you with your career path by assessing your goals and helping you plan your next steps. Your mentor could be anyone from your current head athletic trainer to a former professor to someone youâ&#x20AC;&#x2122;ve met through networking. Choose some-

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LEADERSHIP one who you respect and can talk easily with—you need to be able to take constructive criticism from them. DO’S & DONT’S Once you have positioned yourself well, the last step is landing the open job. That requires being savvy about finding positions, applying, and interviewing. Where to look: Athletic trainers have a great job assistance program through the NATA Web site. As long as you are a member, you have access to the Career Center. This is where employers list approximately 90 percent of the positions that are open to athletic trainers. The NCAA and NAIA also post jobs for athletic trainers. You may want to look at individual college and university Web sites, or even just search the Web. Another great strategy is to alert your network that you are interested in a head position. This way they can be listening for possible opportunities for you. How to apply: To start, always follow the requirements set by the specific job posting. If a school requests two letters of recommendation, be sure to send two. Take time to make your cover let-

ter specific to the job. The goal is to show the hiring committee that your experiences match the qualifications of the position—not just any head athletic training job, but the one at this school. Do some research to find out about the athletic department and what its needs are, then explain how you can fill those needs. For example, from postings on its Web site, you might notice that the school hosts many NCAA regional competitions. In your cover letter, explain any experiences you have in this area. Or maybe you see that there was a rash of ACL injuries on the women’s basketball team—do you have experience implementing some of the latest ACL prevention programs? If so, make sure to highlight that. Should you call the school after sending in your materials? This is appropriate only if you know the person receiving them or someone else at the specific institution. However, it is okay—and recommended—that if someone in your network has a contact at the school, they call and let the contact know you are a great candidate.

If you do not receive a notice in a few weeks stating they have your application, you can call to make sure they have everything they need, but don’t call too frequently. You can politely call every couple of weeks if you do not hear anything. Interviewing: If you advance to a face-to-face interview, remember that first impressions can be wonderful or deadly. Many years ago, I interviewed a young man three different times on the phone for a position we had at our sports medicine clinic. He was our first choice until he stepped off the airplane. He was wearing a cowboy outfit, with blue jeans and boots, a look way too casual for our clinic. After picking him up at the plane, I took him directly to the clinic to meet our staff. My physicians could not get over that first impression and it cost him the job. You need to present the best “you” when first meeting professionals. This starts with dressing and acting professionally. I suggest you always wear a suit and tie if male, and a suit, or nice skirt or pants if female. But make sure the outfit looks good on you. If the suit looks sloppy, then try wearing a sport

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LEADERSHIP coat and slacks. Be conservative in your style and don’t wear anything distracting, such as a too-short skirt or large medallion necklace. Never wear a shirt with a logo from your present school. In addition, polish your shoes or buy new ones. Women should never wear heels that would make it difficult to walk across an athletic field or gym floor. When I interview a potential candidate, I notice their shoes first. I want to know if they take care of their possessions. It also tells me how much they want the job. Did they take time to make themselves look the best they could? Acting professionally means being polite, respectful, and interested. Don’t criticize anything you see and never say anything that might be offensive to anyone you come into contact with during the hiring process. You also need to bring your best manners. I know candidates who did not get jobs because their professional presentation was really weak. You may be taken out to lunch during your interview and this is another area where you will be judged. If you don’t know proper etiquette while

eating at a restaurant, there are classes you can take to learn this. You should also do prep work to be able to answer all questions intelligently. This requires doing some research on the responsibilities of the job at that particular level. For example, if there is drug testing at the school, be prepared

sibly a faculty member. You may ask the contact at the school exactly who is on the committee, then think ahead about each of their concerns and questions they might ask. Just as important, throughout all parts of the interview, be yourself. Use the personality you were given and the

Be ready to be interviewed by a full committee. At a big-time school, this group will often include an assistant or associate athletic director, the head football coach, and a team physician—at the very least. to answer questions about overseeing this process. At the NCAA Division I level, there is a lot of paperwork that is critical—know how to answer questions regarding this area. And be ready to be interviewed by a full committee. At a big-time school, this group will often include an assistant or associate athletic director, the head football coach, and a team physician— at the very least. At smaller schools, the committee will likely include the athletic director, a few coaches, and pos-

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knowledge you have to acquire the position. If you think you need to change your personality or act a certain way to get a job, then I do not believe the job is worth interviewing for. Becoming a head athletic trainer often takes time and patience. You need to gain experience and education and build your network. You need to find the right fit for you. But, by doing those things, you are purposely preparing yourself—allowing good things to happen for you. n

NUTRITION

Inner Strength When it comes to bone health, there are many pieces to the puzzle. It’s likely your athletes are missing some of them in their everyday lives.

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college running back fractures his ankle during preseason workouts and is healing at a very slow pace, surprising the team’s athletic trainers and frustrating his coaches. He spends most of the season on the sidelines. A top high school runner is diagnosed with her third shin stress fracture in two years, causing her to miss a second consecutive state championship cross country meet. She aggressively supplements with calcium and feels she has a healthy diet, so is confused by the repeat injury. A star collegiate point guard fractures her foot during a late-season game. A non-contact injury, she doesn’t recall any twisting or odd landing—it “just happened.” She ends up missing the league’s tournament championships, greatly impacting her team’s performance.

3 4

T&C decEMBER 2010

When we think of unexplained fractures and slow healing of bones, we usually relate these problems with the elderly. However, every year, bone injuries take a serious toll on high school and college athletes, as well as their sports medicine support staffs, coaches, teammates, and families. In many cases, these injuries can be chalked up to sub-optimal bone health. DENSITY EQUALS STRENGTH Bone is a dynamic, growing tissue made up of the protein collagen and several minerals—mainly calcium phosphate. Throughout our life span, bone is continually “remodeled” through resorption and formation. When new bone tissue replaces old, the cells involved in bone formation are called osteoblasts. There are numerous hormones such as estrogen, testosterone, calcitonin, para-

thyroid hormone, and vitamin D (which has hormone-like properties) involved in this process. As healthy children and teenagers develop, bone formation exceeds resorption and their bones become larger, stronger, and more dense. Between the ages of 20 and 30, however, bones do not continue to build density. In fact, bone mass declines throughout the remainder of life. Clearly, it is critical for young people to maximize bone development through diet, exercise, and lifestyle. Michelle Rockwell, MS, RD, CSSD, is a Sports Dietitian based in RaleighDurham, N.C. She works with athletes at North Carolina State University and serves as a consultant to teams and individual athletes nationwide. She is also co-founder of RK Team Nutrition and can be reached at: www.rkteamnutrition.com. TR AINING-CONDITIONING.COM

The workout’s ﬁnished. The body isn’t. Rebuild. Rebound.

Refuel with Chocolate Milk. When the ﬁnal whistle blows, it’s time for student athletes to Refuel with Chocolate Milk. The ﬁrst two hours after the workout is when the body’s real work begins—building and repairing muscles. That takes protein, and lowfat chocolate milk is a natural source of high quality protein. Plus it’s packed with essential nutrients not typically found in other sports drinks including calcium and vitamin D, which can help prevent stress fractures and broken bones. Discover the research that supports milk as an effective post-workout beverage at milkdelivers.org/refuel.

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NUTRITION Bone mineral density (BMD) is a measure of the amount of bone tissue in a certain volume of bone—in other words, bone strength. BMD includes assessment of the calcium content of bones. Research shows that in many cases, BMD is a reliable predictor of fracture risk. Dual-energy x-ray absorptiometry (DXA, previously referred to as DEXA) is a type of x-ray based on bone densitometry. DXA is currently considered the gold standard for measuring bone density. Different areas of bone are measured based on the test and protocol, but common sites include the spine, hip, femur, and wrist. (It is important to not confuse DXA scans with bone scans, in which a radioactive tracer is injected to detect medical problems in bones.) For individuals over 21 years of age, results of DXA scans are expressed in T-scores, which are standard deviations from the mean of expected bone density based on age and gender. T-scores above -1.0 (less than 1 standard deviation below the mean) are considered normal. T-scores between -1.0 and -2.5 are clas-

sified as osteopenia, which means low bone mass. T-scores below -2.5 are classified as osteoporosis, which literally means “porous” bones. The appearance of osteoporotic bone marrow is brittle, with large holes. Normal bone, on the other hand, has small holes and is stronger and more resistant to fracture. Interpreting DXA scan results for individuals under 21 years of age is more complicated since less normative data has been established for this age group. Instead of T-scores, results are expressed in Z-scores. Like T-scores, Z-scores are based on data from individuals of the same age and gender, but they also take into account race, height, and weight. However, more data needs to be collected on the younger population to establish reliable mean scores. When interpreting Z-scores, those with scores less than -2.0 are considered to have “low bone mineral content” or “low bone mineral density for age.” The term osteoporosis is not used in people under 21 years of age unless they also meet other criteria, such as having previously suffered fractures.

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FRACTURE FACTORS What exactly predisposes athletes to low BMD, which research has shown to be a reliable predictor of stress fracture risk? Although genetics play a role, there are numerous other controllable

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In many cases, the greatest benefit of DXA scans in young athletes is to examine and monitor trends. Changes in bone density require six months to one year to accumulate, but they can be very revealing. For example, I have seen a female athlete with a baseline Z-score of -0.7 (normal) develop a Z-score of -2.2 exactly one year later, following disordered eating patterns, a loss of over 15 percent of her body weight, and strict adherence to a vegan diet with very few calcium sources and no supplementation. On the other hand, a female runner increased her Z-score from the “low bone density” category to normal within 18 months, after increasing her intake of calcium and fat, restoring menstrual function, and supplementing with vitamin D. She also improved her running times.

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NUTRITION factors that come into play. Medical History: Having had one stress fracture is believed to be a strong predictor of future stress fractures. Once an athlete incurs a stress fracture, additional attention should be paid to uncovering likely causes and contributors in order to prevent future injuries. Bone Development: Failing to maximize bone development during younger years will likely increase risk of bone problems in athletes during high school and college. The good news is that bone mass accumulation continues through at least the early 20s, so intervention during high school and college years can make a significant acute and life-long impact. Inadequate Calories: When athletes do not consume enough calories to meet needs, it is known as negative energy availability. If this becomes an ongoing pattern, it can lead to low BMD. Low body weight in relation to height is commonly correlated with low BMD. Increasing body weight to a more appropriate range—typically through additional calorie intake or

perhaps strength training—can improve BMD. Male athletes should not be disregarded in this category. Energy deficit, undereating, and low levels of testosterone can contribute to decreased levels of BMD in men. Menstrual Abnormalities: Current or previous menstrual abnormalities such as amenorrhea (absence of menstruation) or oligomenorrhea (sometimes defined as fewer than four periods in one year) are considered strong predictors of low BMD and fracture risk. Menstrual dysfunction often occurs secondary to low estrogen levels. Low estrogen plays a role in weakening bones, partially through its association with weakened concentrations of blood formation markers. It has been estimated that for every year of low estrogen levels, a five to 10 percent decrease in bone mineral density may occur. There are multiple causes for menstrual abnormalities, some primarily medical in nature. However, chronic consumption of inadequate calories has been shown to have a strong relationship to menstrual problems. Thus, treat-

ing menstrual abnormalities with birth control pills or other hormones may or may not be helpful to increasing bone mass, since a low calorie intake appears to be the root of the problem. The Triad: The Female Athlete Triad —the known relationship among disordered eating, decreased BMD, and menstrual abnormalities—is a clear cause of bone injury and poor bone healing. While some individuals with the Female Athlete Triad have distinct clinically diagnosable eating disorders such as anorexia nervosa or bulimia nervosa, there are numerous others whose eating behaviors would be classified as disordered eating. These individuals are also at risk for bone problems. Intense Running Training: In general, weight-bearing exercise enhances BMD. However, at the high mileage level required in some sports, BMD can actually be compromised. Highly competitive runners and soccer players, for example, have been shown to have reduced BMD (regardless of diet and menstrual history) compared to control subjects in a few research studies. In terms of running, it seems that there is

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NUTRITION a threshold, at which point BMD can be hindered instead of helped, but it varies widely by individual based on previous training, diet history, and body weight. Research in this area is just starting to take hold. Typically, women are often thought to be at greater risk for stress fractures.

However, in distance running and track and field, several studies have reported a similar incidence among high school and college-aged males and females. Calcium Intake: According to the Food and Nutrition Board’s Dietary Reference Intakes, high school and college-aged individuals should consume

Follow Up The three athletes mentioned at the beginning of this article are all real people who needed real solutions. An individualized treatment plan was developed for each, with good results. The running back with the slow-healing ankle fracture perplexed the medical team because he was very compliant to treatment and rehab. He also said he drank a gallon of milk every two days, in addition to consuming several other dairy sources, so calcium intake was not likely the problem. However, a vitamin D blood test revealed a level of only 11 ng/ml, while the normal level is 32 ng/ml. The athlete was not able to absorb all of the calcium he was taking in due to a vitamin D deficiency. It turns out he was training and rehabbing almost exclusively indoors, and distinct improvements in healing came after six weeks of high-dose supplementation. The high school runner spent a lot of time exploring her repeated stress fractures with her sports dietitian and pediatrician. She was a very conscientious eater, consuming about 1,000 milligrams of calcium a day along with an additional 600-milligram supplement. She regularly read books and magazines about nutrition and had most every food label memorized. She was aiming for 2,000 calories per day, which she believed to be appropriate since she was smaller than the average “adult” at only 109 pounds. She reported that she did not start menstruating until age 16 and since that point, had only had three very erratic periods. This athlete was diagnosed with the Female Athlete Triad. She did not have a clinically diagnosable eating disorder, but she did have menstrual abnormality, decreased bone mineral density (her Z-score was -2.8), and was chronically in negative energy balance. She was burning about 3,200 calories a day, and over time, that 1,200 calorie per day deficit accumulated and became problematic. Although it took some work to convince the athlete that her energy needs were significantly higher than 2,000 calories, she complied. Her menstrual cycle became normal after six months on a higher calorie diet and she is now in her second year running for an NCAA Division I program where she has not experienced any more bone injuries. Our point guard with the surprise foot fracture had never really worried much about her nutrition. At 14 percent body fat and great strength, she could eat anything she wanted—and she did! Her diet contained a lot of fast foods, soda, and convenience store foods. Analysis by her sports dietitian revealed that she was not only consuming less than a quarter of her calcium needs, but that she had been doing so since she was a young child. She had several lactose intolerant family members and never consumed milk or dairy products except an occasional slice of pizza. A good calcium supplementation regimen was key for this athlete’s healing.

T&C decEMBER 2010

1,000 to 1,300 milligrams of calcium per day. However, research has shown that, on average, high school and college students fail to consume this recommended amount. High school students in particular are not even meeting half of their daily needs. Broad-spread calcium intake has been shown to be so inadequate that the most recent Dietary Guidelines for Americans (2005) lists improving milk, dairy, or other calcium intake as a specific target. Furthermore, it has also been shown that athletes may have enhanced calcium needs for various reasons. Thus, calcium intake should clearly be addressed, preferably via diet, or supplements if necessary. Although not known to be extremely common, some athletes lose a significant amount of calcium through sweat. Calcium is one of many electrolytes lost in sweat, so someone who has a high concentration of calcium in their sweat or who simply sweats at a high volume regularly may need to increase their calcium intake. Consider the compilation of calcium issues that may occur in one athlete. Suppose he or she consumes calcium below recommended levels, doesn’t tolerate dairy well before practice or competition, and has a high sweat calcium rate. This individual may have higher risk of calcium deficiency—compromising bone health—than obvious at first glance. Vitamin D: An extensive amount of information about vitamin D and its role in health and disease prevention has been uncovered in recent years. However, it has been understood for quite a long time that vitamin D is essential for calcium absorption. Thus, increasing calcium may be fairly futile if vitamin D levels are sub-par. A recent report showed that 60 percent of Americans take in too little vitamin D, based on the current Recommended Daily Allowance of 400 IU per day. Many experts feel this level is actually too low and athletes are frequently advised to supplement with 1,000 IU per day. Other Vitamins and Minerals: There are additional vitamins and minerals that are known to be associated with bone health and mass, namely vitamin K, potassium, and magnesium. There are not specific recommendations for these micronutrients as they relate to bone, but a diet rich in fruits, vegetables, TR AINING-CONDITIONING.COM

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NUTRITION dairy, and whole grains can help athletes obtain ideal levels of these nutrients. Other Macronutrients: Even if an individual is consuming adequate calories, studies have shown that dietary fat and protein are both contributors to healthy bones. Many athletes develop the mindset that extremely high carbohydrate diets are important to enhance performance, but healthy fats and lean proteins are also critical. However, it is

and not miss any playing time with a stress fracture. I suggest focusing on the following areas: • The bone consequences of consuming too few calories or of chronic dieting: Some athletes, both male and female, chronically under-consume calories either intentionally (perhaps as a method of weight control) or unintentionally due to time demands, lack of appetite, or poor education about calo-

Researchers have learned vitamin D synthesis from sunlight is not quite as efficient as once believed and that sunscreen blocks up to 95 percent of vitamin D synthesis. This is particularly relevant for athletes who participate in indoor sports or train minimally outside. possible that extremely high protein diets may decrease BMD. Other Medical Problems: Abnormalities in thyroid hormones and other medical problems may contribute to decreased BMD. Certain medications may also impact BMD. Athletes should consult with their physician about any bone effects their health conditions or prescribed medications may predispose them to. Tobacco and Alcohol Use: Researchers have shown a relationship between regular tobacco use and consumption of less than eight to 10 alcoholic beverages per week and a weakening of bones. Education on this negative byproduct of tobacco and alcohol use can be beneficial to athletes. ACTION STEPS Because there are so many factors related to keeping bones strong, advice to athletes in this area must be multipronged. It should include education, screenings, and teamwork. When educating high school and college athletes, it’s critical they understand they are in a bone-building life phase—taking care of their bones now can help them prevent osteoporosis and other bone-related issues later in life. Up to 45 percent of women and 30 percent of men over 65 years of age experience osteoporosis or non-traumarelated fractures. But since convincing young people to worry about their future health is not always effective, take the time to explain how all the factors mentioned above can help them stay strong now 40

T&C decEMBER 2010

rie needs to support their daily expenditure. They need to know the negative effects of such practices. • How to include adequate protein and healthy fats in their diets: A big greasy bacon-cheeseburger has a lot of protein and fat, but also a lot of calories. Educate athletes on how to consume lean protein, such as chicken and fish, and fats from heart-healthy oils, nuts, avocados, and olives. • Adequate consumption of calcium-rich foods or supplements: It is recommended that athletes get 1,500 milligrams a day of calcium. Provide suggestions on how athletes can add calcium to their diet through milk, lowfat cheese, and yogurt. Some athletes consume minimal or no dairy products because they are lactose intolerant, vegan, or have some discomfort after consuming dairy. Medications are available to help those with true lactose intolerance, and lactose-free dairy products or calcium-fortified soy milks, yogurts, and cheeses are excellent alternatives. Salmon, almonds, fortified cereals, and some green vegetables are also good calcium sources. • How to get enough vitamin D: Researchers have learned vitamin D synthesis from sunlight is not quite as efficient as once believed and that sunscreen blocks up to 95 percent of vitamin D synthesis. This is particularly relevant for athletes who participate in indoor sports or train minimally outside. People living at a similar latitude to Atlanta, Ga., are likely to need two hours of sunlight to obtain adequate vitamin D synthesis. Those with dark-

er skin typically have lower levels of vitamin D. • Consequences of tobacco and alcohol use on bones: Today’s studentathletes often receive preventative education about using tobacco and alcohol. Letting them know about its negative effects on bone health can give them one more reason to say no to these products. Screenings can also be helpful in spotting and preventing bone problems. To start, consider DXA screening for athletes, at least those with particular risk factors for low BMD. DXA testing costs anywhere from $200 to $400, but is covered by many insurance companies in certain scenarios (such as history of stress fractures or an eating disorder). Levels of vitamin D can be checked through blood tests, which has proven beneficial for many collegiate programs and individual athletes. A blood level of 32 ng/ml of 25-hydroxy-vitamin D is recommended and some experts feel that as high as 50 ng/ml is appropriate. A common supplement regimen for low vitamin D levels is either 1,000 to 1,500 IU a day for eight weeks or 10,000 IU once a week for eight weeks prior to retesting. If you do not have access to vitamin D testing, there is little risk in taking 1,000 IU per day. Finally, teamwork is also important. Athletic trainers, strength and conditioning coaches, sport coaches, and team physicians all play roles in helping athletes achieve bone health. Coaches should understand the possible effects of high mileage training and should be encouraged to limit mileage or alter the workout type or intensity when an individual has low BMD. Athletic trainers should talk with athletes about their menstrual cycles and those with abnormal menstruation should be screened by a physician. In addition, sports nutritionists can be included on the team to provide education and counseling for individual athletes. High school and college athletes often take bone health for granted. Unless a fracture rears its ugly head, they trust that the structure helping them to run, jump, and throw is solid. But a clearer understanding of how bones stay strong and some preventative methods can go a long way toward ensuring our athletes stay healthy today and tomorrow. n TR AINING-CONDITIONING.COM

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Special Delivery At Texas Christian University, pitchers are trained to be fast, powerful, and explosive, while also taking into account rotational demands and individual imbalance issues. By Zach Dechant

he development of baseball pitchers poses interesting questions for a strength and conditioning coach. Should they follow the same program as the rest of the team? Should they do upper body exercises with weights? Should they even be in the weightroom at all during the season? Here at Texas Christian University, we firmly believe that pitchers aren’t made of glass, as some baseball team coaches seem to think. They are athletes, and we treat them as such. The act of pitching is an explosive total-body movement, and there is nothing slow about it. Thus, our overarching goal in training pitchers is to make them fast, powerful, and explosive—so that’s how we train. However, several factors separate pitchers from the rest of the team and these should be taken into account when developing a training program. For example, due to the one-sided rotational demands of their position, pitchers can easily develop imbalances that may lead to injury. Another challenge to creating a sound conditioning program for this population is that while they are typically lumped together because they occupy

Kyle Winkler helped the Horned Frogs to their most successful season ever in 2010, which included a trip to the College World Series. Michael Clements

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Zach Dechant, SCCC, USAW, is an Assistant Strength and Conditioning Coach at Texas Christian University, where he oversees athlete performance for the baseball team and assists with football. For more information on strength and conditioning from Zach, visit his blog at: zachdechant.wordpress.com. T&C DECEMBER 2010

sport specific the same position, pitchers are used in different capacities on the mound. A pitching staff runs the gamut from inexperienced freshmen to seasoned veterans, from starters to relievers, from those who may pitch on back-to-back days to others who need days to recover between outings. With these variables in mind, we can begin to solve the complex problem of how to best develop each athlete. We’ve found that taking an individualized approach to developing players’ programs is an effective way to train our pitchers. Since each athlete’s body tells a different story, we start by using a screening process as the basis for forming our pitchers’ strength and conditioning

have added to it and adapted it to fit the needs of a baseball pitcher. This included changing the order of the FMS slightly to help with the flow of the process. I’ve also found that with pitchers, it’s important to do a more thorough evaluation of the throwing shoulder, thoraco-scapular complex, and the hips since these are common areas where pitchers have imbalances. We start each pitcher with a standard evaluation that includes range of motion (ROM) testing and looks for impingements and tightness—especially in the trunk and shoulders. What I find here determines how the rest of the evaluation proceeds. Athletes who pass the initial part of the screening with flying

Each pitcher’s shoulder is measured at least twice during the season. A deficit in shoulder rotation generally means there is a deficit in glenohumeral internal rotation—a natural adaptation to throwing, but one we can’t let get out of control. plans. Then, we work them hard where they need it, while avoiding vulnerable areas, with the goal of increasing their strength, explosive power, and agility. OUR SCREENING PROCESS Every pitcher who walks through our doors is put through a movement screen. This is a multi-step evaluation that clues us in to a multitude of issues in each of our athlete’s bodies. A lot of schools have athletes go through a screening process, but never utilize the information effectively. In our case, each player’s personal strength program is built upon his screening results. Though the bulk of the work we do will be the same for each pitcher, exercises to correct deficiencies and imbalances will vary, as well as those used when a pitcher is injured. We screen each pitcher three different times throughout the school year (plus another two or three looking at shoulder rotation only), so we are always collecting new information. The players’ programs continually change and grow from the information that we compile since new imbalances can pop up even while we’re working to correct existing ones. The goal is to stay ahead of an injury by preventing it in the first place, so it’s important to continue testing throughout the year. I’ve utilized Gray Cook’s functional movement screen (FMS) for years, but 4 4

T&C DECEMBER 2010

colors don’t need to perform any more evaluation exercises, but if they have pain, ROM limitations, or movement dysfunction, we take a deeper look. Although each athlete is different, pitchers often join our program with similar imbalances. For example, we screen for tightness in the lats and pec minor because pitchers are typically too tight in these areas. We also see a loss of internal rotation in the shoulder of the throwing arm. When too much ROM is lost, it can spell disaster for a pitcher— including chronic shoulder problems that eventually require surgery. Perhaps the most important step in our screening process is a thorough evaluation of the throwing shoulder. This includes measuring total glenohumeral rotation and checking for proper tissue length with a goniometer, as well as asking the athlete about pains, pinches, or any problems they may be experiencing in their shoulder. Each pitcher’s shoulder is measured for total rotation four to five times throughout the year—including at least twice during the season because deficits appear quickly when an athlete is throwing a lot. We’re looking to make sure a pitcher doesn’t lose ROM in his throwing arm. A deficit in shoulder rotation generally means there is a deficit in glenohumeral internal rotation—a natural adaptation to throwing, but one we can’t let get out of control.

When an athlete does show a deficit in rotation, we work to eliminate it immediately. Remedies range from gently stretching internal rotation every day, to soft tissue work, to thoracic spine mobility work until the issue is under control. The other area that is directly tied to all shoulder issues is the scapula. The scapula is the most important area for proper functioning of the shoulder, and quite often, pitchers arrive on campus with some form of scapular dysfunction. We make sure to train the scapula for proper movement, such as upward rotation, as well as depression and retraction. Within these movements, we want the scapula to be stable and provide a proper platform for glenohumeral movement. Studies have shown that pitchers’ shoulders (as well as their elbows) lose ROM following an outing. This is especially prevalent in starting pitchers. The greatest loss shows up 12 to 24 hours after they’ve thrown, so the day after each mound appearance, we gently restore each pitcher’s shoulder and elbow ROM through light stretching and soft tissue work with foam rollers, tennis balls, and a self-roller massager called The Stick. The upper body isn’t the only area where imbalances occur, however. We commonly find the hips to be an area of concern. The front-side hip often loses internal rotation, and an inability to fully rotate over the hip can mean problems in the shoulder and arm. We have our pitchers stretch for internal rotation by trying to touch their knees together while their feet are spread apart. We’ll then work to integrate that specific flexibility into movements like hurdle duck-unders or a diagonal lunge pattern. IN THE WEIGHTROOM Depending on the time of year, our pitchers perform anywhere from four to seven total body movements during their weight lifting sessions. Including warmup and our speed and movement work, total training time for highintensity sessions is generally 70 to 90 minutes, three days a week. Though each lifting session is a total -body workout, we alternate between an upper-body and lower-body emphasis. The foundation of our lower-body movements includes the back squat, front squat, and Romanian deadlift. However, TR AINING-CONDITIONING.COM

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sport specific we often individualize programs, especially for our pitchers who are unable to back squat due to shoulder injuries. These athletes will usually use the safety squat bar instead. Our main upper-body movements include the reverse pull-up (also known as the inverted row) and pushups. I believe reverse pull-ups are one of the best posterior upper-body exercises a pitcher can perform. Not only does it teach proper scapula movement, but the move also requires stability throughout the entire trunk along with glute activation. And I believe pushupsâ&#x20AC;&#x201D;provided they are done correctlyâ&#x20AC;&#x201D;are one of the best overall exercises any throwing athlete can perform because of the benefits for core stability. I especially like using pushups with a DB row and rotation. While they are great for the serratus anterior, when pushups arenâ&#x20AC;&#x2122;t fully completed at the top, the serratus isnâ&#x20AC;&#x2122;t activated. I also always make sure athletes arenâ&#x20AC;&#x2122;t letting their hips and core sag at any point during the movement. Our pitchersâ&#x20AC;&#x2122; shoulder health is key, so we take major precautions in the weight-

room. For example, our pitchers donâ&#x20AC;&#x2122;t do any overhead moves in the â&#x20AC;&#x153;high fiveâ&#x20AC;? position. Most of our exercises utilize a neutral grip including all of our pullups, pushups, and any dumbbell pressing variations we may do. For back work, we always perform at least a 2:1 ratio of posterior upper-body movements to anterior. Depending on the time of year, we will sometimes work at a 3:1 ratio. Also, some athletesâ&#x20AC;&#x2122; imbalances will dictate that they do nothing on the front side and focus all of their work on strengthening the posterior muscles. Nearly every pulling movement we do is taught with retraction and depression of the scapula. We put an emphasis on stabilizing the scapula in these movements so that the shoulder complex doesnâ&#x20AC;&#x2122;t become compromised. When training the scapula, we make sure to emphasize the lower and middle trap and serratus anterior. These muscles are very important in stabilization and safe upward rotation, which is hugely important for an overheadthrowing athlete. The thoracic spine receives a lot of

attention as well. Training mobility throughout the thoracic spine should be a high priority in any throwing athlete. Being able to rotate and fully extend eliminates compensations that can cause low back issues, as well as problems related to the shoulder and elbow. Recovery sessions include soft tissue massage work using foam rollers, sticks, tennis balls, or lacrosse balls. Each athlete will then perform their specific movement training, which is based on their screening results. One athlete may perform specific thoracic spine mobility work with an exercise like a reverse lunge with a rotation, while another athlete works on increasing torso stability through a bird dog pattern or modified pushup. Next is a rotator cuff, scapula, hip, and core activation circuit. This is lowintensity work that includes exercises such as hip raises and clamshells for the glutes, some type of stabilization work such as Iso Abs or planks for the torso, and some form of scapular or rotator cuff work like Yâ&#x20AC;&#x2122;s, or any number of external rotation variants. The entire circuit lasts about 10 to 15 minutes.

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Athletic Management T&C DECEMBER 2010 1/6-Page Vertical

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from Training & Conditioning

Recognition, Treatment, and Prevention of Exertional Heat Illness

ABOUT THE AUTHOR

By J. Allen Hardin Exertional heat illness is a treatable, preventable, but potentially life threatening condition. The ability of the body to regulate core temperature depends on many factors, both internal and external. Further, the combination of heat stress, dehydration, and exercise imposes perhaps one of the most severe physiological challenges for the human body. Successful management requires early recognition and treatment, necessitating an understanding of factors associated with heat intolerance as well as etiology, signs and symptoms.

J. Allen Hardin, PT, MS, SCS, ATC, LAT, CSCS Allen Hardin joined the University of Texas sports medicine in 1997 and became the CoDirector of Sports Medicine in 2001.

Click on â&#x20AC;&#x153;CEUs & Coursesâ&#x20AC;? on the toolbar at the top of the page at:

www.training-conditioning.com Circle No. 130

sport specific Finally, the athletes finish with any specific corrective mobility and flexibility work that we have assigned based on their screening results. This is an example of where each athlete’s training program differs slightly. In total, our recovery training sessions are only about 30 to 40 minutes long, depending on each pitcher’s needs. Perfect pOSITIONING Our pitchers spend the first three weeks of every off-season developing what we call the athletic position. This is just what it sounds like—teaching the athlete to be in a proper position for movement. Hips should be pushed back with the knees bent, and the chest out over knees, almost like a middle linebacker set for a play. While it may not be a common position for pitchers on the mound, we teach it to every athlete in every sport as it is fundamental to most athletic movements. Nearly every movement that is

involved in deceleration training, the final six weeks of the fall are spent on sport specific movements. Our specific movement training involves nonprogrammed, reactive agility work. Essentially, we are trying to duplicate the movement patterns that a pitcher will face in fielding. For example, a pitcher will go through his throwing motion while facing a wall located about 20 feet away. As he completes this motion, a player standing behind the pitcher will throw a tennis ball to a random spot against the wall. The pitcher must immediately react and field the ball. We start with our pitchers fielding the ball and going through the motion of a throw to first base, then progress to calling out a base as the pitcher fields the ball, which forces them to adjust and throw to the correct base. Rotational training is another major aspect of our off-season. It’s a part of every training session the athletes com-

The majority of our speed work consists of training 10- to 30-yard accelerations. We do this from a number of different starting positions, including blind starts from the players’ stomachs to athletic position starts facing various directions. taught in the weightroom and on the field stems from the athletic position. We put a high priority on this training and review the athletic position over and over again throughout the year. Once the athletes understand the position, we move into deceleration training where we teach our pitchers body control and the ability to slow down and stop in a controlled manner. Most baseball fans can recall a pitcher blowing an easy bunt play because he slipped or couldn’t gather himself in time to make an accurate throw. This happens all too often because pitchers are not taught to accelerate, get their body under control, and decelerate while fielding a ball. We teach them using cone and line drills. Our main drill is a five-yard out and back and 10-yard out and back shuttle. In addition to the typical sprints and backpedals, we also use a lot of lateral movements such as shuffles. Each line can be used to teach deceleration or quickness. Our main goal is for the players to know how to stop and control their bodies using the athletic position. After spending some time perfecting the athletic position and the movements 48

T&C DECEMBER 2010

plete through all 15 weeks. We spend the first three weeks teaching general rotational movement patterns utilizing hip and thoracic spine rotation. From there, we move to strength development in the transverse plane. And the final six weeks of the fall we begin to implement power development in our rotational movements in the form of medicine ball work like throws and slams. We start off doing these in a speed-strength complex, super-setting throws with a strength movement, and eventually progress to nothing but med ball throws. SPEED & EXPLOSIVENESS During the fall, our pitchers train five days a week and have weekends off. Monday, Wednesday, and Friday are total-body high-intensity work days, and then we build recovery into our Tuesday and Thursday workouts. Each high-intensity training session begins with our dynamic warmup and speed and movement training program. This includes linear and lateral movements, as well as jump training, and usually lasts 30 to 40 minutes. I believe strongly in the benefits of

speed training for all athletes, even for a pitcher who isn’t too worried about how fast he is. Just to name a few benefits, proper speed training helps improve a pitcher’s stretch reflex, enhances coordination, aids in increasing all around hip motion, and complements strength and power development. It falls directly in line with my overall philosophy of training pitchers to be fast, powerful, and explosive. “Train fast to be fast” is how I approach speed work for all of our players, so we utilize short sprints and long recoveries. The majority of our speed work consists of training 10- to 30-yard accelerations. We do this from a number of different starting positions, including blind starts from the players’ stomachs to athletic position starts facing various directions. A typical training session averages 200 to 300 yards of total volume of 10-, 20-, and 30-yard sprints. It’s not until the final six weeks of the fall semester that we begin any type of energy system training with our pitchers. This work starts late in the semester because we want the majority of our year spent developing a foundation of speed and power. I look at what a pitcher does on the mound and structure our training to match it. In an actual game, a pitcher might throw six pitches then have to field a bunt. He may throw two more and have to back up third base on a triple to the gap. Then he may throw three more pitches and have to back up home or cover first base. In essence, we duplicate our pitchers’ energy system demands by using a fourto six-pound medicine ball for a series of throws and movements including sprints, shuffles, and backpedals. We may start with three series of eight to 10 throws per set and work our way up to four to five series of 12 to 15 throws with anywhere between two and 10 movements per set. This specific conditioning continues through the fall and leads up to the first week of the season. There is no “one size fits all” way to train your pitchers, but regardless of their exact needs, you must train them as athletes and not keep them out of the weightroom. Here at TCU, individualizing programs, putting an emphasis on total-body explosive movements, and moving safely and effectively have proven successful for our pitching staff, and these principles can do the same for yours, too. n TR AINING-CONDITIONING.COM

College Hoop Dreams on the TRX®

By Matt Durant, M.S. Matt has been the Director of Strength and Conditioning at the University of La Verne for eight years. He oversees the programming for in season and off season training for all 16 sport teams, consisting of 400 student athletes. TRX Overhead Squat

At the University of La Verne, the TRX® Suspension Trainer™ is used by every one of their 16 sports teams, most notably in their basketball program where the TRX affords the team the freedom to work on many different aspects, not just strength and conditioning but also mobility. We have seen a number of basketball players who struggle to perform an overhead squat. To learn the movement properly, we have the athletes do a TRX Overhead Squat. The athletes place their hands in the TRX foot cradles, allowing them to unload their weight, sit back on their heels, keep their torsos upright and get a better range of motion than they would if we just put a bar in their hands.

TRX Pistol Squats

Basketball players generally have longer limbs, which can create problems with squatting. Unilateral squats, or TRX Pistol Squats, are another exercise the coaching staff at ULV does with each athlete, again allowing for greater range of motion throughout the exercise. If an athlete needs to regress the movement, he or she can use both handles to unload some weight. For stronger athletes who are looking for ways to further challenge themselves and progress the exercise, they can put the TRX into single handle mode, using the TRX less and less to assist the movement.

TRX Push-up to Press

Much of the game of basketball is played overhead. To build the requisite upper body strength, the ULV ballers perform a new combo movement they created called the TRX Push-up to Press. Start with the TRX in single handle mode, one foot suspended and hands on the ground in pushup position. Perform a push-up and then walk the hands back so the feet begin to walk back. After each push-up, continue to walk the feet and hands back. The goal is to eventually perform an inverted, assisted press or hand stand.

TRX Partner Row

ULV coaches prescribe a 2:1 ratio of pulling to pushing exercises, and the TRX provides many different variations for pulling exercises. “One we especially like is the TRX Partner Row,” says Durant. “It is essentially a TRX Elevated Row, but it is a more advanced exercise and incorporates the adductors, glutes and core to remain elevated.” To start, Partner A stands under the anchor point holding the TRX handles; his feet are flat on the ground. Partner B stands near A’s feet, and with his weight in the TRX, A lifts both legs up and squeezes his knees around B’s hips. (TIP: Stronger athletes can squeeze their partner’s hips with their feet and ankles rather than their knees.) Once in that position, Partner A performs inverted rows. The trick is to keep your core tight and not use your hips for momentum.

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electrotherapy equipment a division of Amrex-Zetron, Inc. 641 East Walnut Street, Carson, California 90746 Tel: (800) 221-9069 or (310) 527-6868 / FAX: (310) 366-7343 Website: http://www.amrex-zetron.com E-mail: amrex@amrex-zetron.com

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state The Pressure Positive Company 800-603-5107 www.pressurepositive.com

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Industry Trend: Incorporating a variety of solutions to effectively deal with soft-tissue dysfunction is the new standard in manual therapies. In addition to professional therapy techniques, it’s important to engage patients with simple and effective self-care strategies to complement your treatments between visits.

NZ Manufacturing, Inc. 800-886-6621 www.nzmfg.com

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With 63 percent of volleyball injuries being related to jumping, NZ recommends its TurfCordz™ Jump Belt. The Jump Belt strengthens leg muscles used to jump explosively off the ground in order to spike, block, set, and dive.

manufactures manual, ergonomic massage tools that work equally well in a clinic or home setting. By teaching your patients to confidently self-administer compression to their trigger points and overstressed muscle tissue, you will ensure that you are the practitioner they turn to when more serious muscle discomfort disrupts their training regimens. Benefits to include: • Drug free • No side-effects • Can be used anywhere • Saves fingers and hands from overuse

California University of Pennsylvania. 866-595-6348

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Industry Trend: Busy professionals who want to continue their education need convenient, high-quality options. California University of Pennsylvania has responded to this growing need with Global Online, which offers in-demand programs in a format that suits busy schedules. Benefits: Cal U was ranked No. 1 for Internet-based degree

programs, according to SR Education group’s Guide to Online Schools. Global Online allows students the opportunity to complete coursework anytime, anywhere—all you need is a computer with an Internet connection. Degrees include rehabilitation sciences, sport management studies, sport psychology, wellness and fitness, and performance enhancement and injury prevention.

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industry

Industry Trend:

Benefits: The Pressure Positive Company

www.calu.edu/go

of the

Benefits: TurfCordz™ Jump Belts prevent injuries,

increase power endurance, and strengthen leg muscles.

McDavid 800-237-8254

www.mcdavidusa.com

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Industry Trend: One of the key trends seen in the team sports arena centers around the use of compression apparel. Benefits: McDavid focuses its efforts around a full package of compression to accommodate athletes before, during, and after competition. For the past 20 years, the company has offered compression garments in shorts, tights (pants), and shirts, as well as well as in arm and leg sleeves. New additions include McDavid’s TCR Recovery Suit and TCR Lower Leg Recovery System. Utilizing true compression, the TCR line, aids in the post-workout/post-competition recovery process, helping athletes to recuperate from grueling workouts faster.

T&C DECEMBER 2010

state

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industry

Accent Ventures 610-812-9134

www.vibrosphereusa.com

MedPac, Inc. 800-414-9031 Circle No. 504

www.medicalbags.com

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New Technology: MedPac Bag’s newest

New Technology: Vibrosphere, a balance

board with an incorporated vibrating platform, is a new and unique European device now being introduced in the United States. Vibration therapy and training, when done correctly and safely, is a highlybeneficial exercise program with little or no negative musculoskeletal stress. The use of various vibration devices is increasing in certain areas of sports, exercise, rehabilitation, and preventive medicine. Vibration exercise leads to a rapid and energy-sparing warm-up and helps improve flexibility, jump height, and muscle power. In medicine, there is evidence to suggest that whole body vibration improves balance in elderly patients and reduces pain.

products are the SlingPac 1 and SlingPac 2. With padded shoulder straps, they’re designed to wear comfortably as sling bags and offer easy access for on-the-job use. The spacious, main compartment can be customized with adjustable, rigid dividers. Like all MedPac Bags, SlingPacs are crafted of rugged, waterresistant, ballistic nylon with thick foam padding. The Sling 1 is 18” tall x 10” wide x 7” deep. The Sling 2 is 12” tall x 10” wide x 7” deep.

Benefits:

Benefits: SlingPac 1 and SlingPac 2 feature satellite pockets for grab-and-go convenience, detachable raincovers, interior pockets, and elastic loops inside to secure and organize supplies.

• Simultaneous balance and vibration enhance proprioception for more functional training • Improves balance and stability • Multi-sensory training improves hand-eye coordination. • Can be used for upper, lower, and core exercises • Portability allows personal trainers, athletic trainers, and strength coaches to bring vibration and balance training on the road

Cho-Pat 800-221-1601

www.cho-pat.com

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New Technology: Cho-Pat’s Plantar Fasciitis Wrap is specially designed to provide relief from the pain and discomfort caused by plantar fasciitis. Unlike other products for the foot, the wrap’s exclusive focus is alleviating the pain of plantar fasciitis and playing a role in healing. Other supports use elastic tension to pull the arch upward to relieve stress to the region. The Plantar Fasciitis Wrap has a “plantar pad” under the arch which uses the natural stepping motion to apply compression to reduce stress and alleviate inflammation.

PRO Orthopedic 800-523-5611

www.proorthopedic.com

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New Technology: PRO can now produce custom-fabricated supports and braces to fit special needs or hardto-fit athletes. Normal turnaround time is 48 hours, with 24-hour service available upon request. Special restrictors, padding, and strapping can now be completed in a timely fashion to keep athletes in the game. Benefits: Products are custom-fabricated for a perfect fit, with special padding or restrictors to protect injuries and prevent new ones. When compared to specialty taping, PRO devices save time and money.

Benefits: The Plantar Fasciitis Wrap applies needed stabilizing pressure directly to the fascia, disburses the forces applied to the flexor muscle connections, and allows the user to gradually return to normal activities during healing process.

T&C DECEMBER 2010

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state SpiderTech Inc. 416-494-1444

www.nucapmedical.com

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New Technology: SpiderTech is the leading provider of specialized kinesiology taping products that naturally reduce pain and restore strength and mobility to injured and sore muscles. These products are offered in roll format, pre-cut I, X, and Y strips, and 16 functionally-designed, ready-to-apply Spiders. SpiderTech was created by Dr. Kevin Jardine, a Toronto-based chiropractor and advisor to numerous professional cyclists, runners, triathletes, and sports teams to provide a standardized and clinically effective means of using kinesiology taping within practice and competition. Benefits: SpiderTech applications are a drug-free therapeutic solution that use tape to naturally stimulate the nervous system through skin contact and restore strength and mobility to injured and sore muscles. The company’s re-invention of kinesiology tape methodologies in the form of “pre-cut” applications, along with industry-leading, evidence-based education on the clinical use of kinesiology taping, has propelled SpiderTech into becoming the lead provider of kinesiology taping products and education.

Hyland’s/TxOptions 800-234-8879 www.txoptions.com

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Industry Trend: As athletes and athletic trainers become more knowledgeable about the potential downside of allopathic medicines, the trend toward more holistic, non-toxic therapies is driving the industry to rethink what people put into their bodies. Homeopathic medicines that can reduce recovery time and increase performance without side effects, contraindications or drug interactions are becoming increasingly soughtafter. Homeopathic products that contain arnica, the premier medicine for reducing swelling, bruising, and muscle soreness from injury or overexertion, fit the bill perfectly. Formulas like Hyland’s Muscle Therapy Gel, which heals sprains, strains, and joint pains, are even more beneficial.

Samson Equipment 800-472-6766

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www.samsonequipment.com

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Industry Trend: The strength and conditioning community is always coming up with methods for implementing movements and exercises in new and exciting ways, whether by necessity (due to injury) or as an integral part of the training program itself. Likewise, weight equipment manufacturers are constantly designing new machines that take basic exercises and implement them in new ways. Samson’s Belt Squat is just such a piece. With the Belt Squat, athletes can perform a squat movement from an upright position, and still overload themselves while taking pressure off the lower back. Benefits: The Belt Squat provides new options for training the lower body. Athletes can still train heavy on squats, with the same natural movement, even if they are injured in the upper body. The unique design is compact, so vital space in the weightroom is not wasted. The design also allows for band training, providing yet another option for training the lower body.

Dynatronics 800-874-6251

www.dynatronics.com

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Benefits:

Industry Trend: MRSA continues to be the focus in athletic training facilities across the country, and research has proliferated in an effort to stop this virulent form of staphylococcus. In a book published in 2008, Proceedings of LightActivated Tissue Regeneration and Therapy Conference, edited by Waynant and Tata, a research team stated: “Blue light produced a dose-dependent bactericidal effect on MRSA (p<0.001), achieving a kill rate of 96.7 percent, 90.8 percent, and 83.8 percent respectively during each of the three trials.” The study concluded that “blue light emitted by the SLD source destroys MRSA in vitro” and suggested that a similar bactericidal effect may be achieved outside the laboratory.

• Helps the body recover quickly, safely, and naturally • Provides efficacy without side effects, drug interactions, or contraindications • Allows athletes to spend more time on the field and less time in the athletic training room

Benefits: The Dynatron 405 infrared/blue light probe produces the same wavelengths used in this groundbreaking research. It is a safe, fast, and inexpensive way to apply blue light.

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T&C DECEMBER 2010

Therapy Technologies Dynatron X3

The DX3 is capable of delivering three independent light therapy treatments simultaneously (one light probe and two unattended pads for a total of 16000mW of light).

• Laser Class: II • FDA Approval: Provides topical heating for temporary increase in blood circulation, temporary relief of minor muscle and joint aches, pain and stiffness, relaxation of muscles, and treatment of muscle spasms, minor pain, and stiffness associated with arthritis. • FDA Submission: K051261: The Intended Use/ Indications For Use stated herein are consistent with the cleared indications for the predicate devices (Same as FDA Approval). Performance Standards: 21 CFR sections 1010 • Other Uses: The Dynatron X3 device is compatible with the following: Dynatron XP Infrared Light Pad, D405 Infrared/Blue Light Probe, D880 Plus Infrared/Red Light Probe, and the D890 Infrared Laser/Red Probe. • Market History: Market Release 2006. Independent Research on Blue/Infrared Light Therapy on MRSA published in The Journal of Photomedicine and Laser Surgery, vol. 27, No. 2, April 2009. • Multiple Energy Levels / Wave Lengths: User may select dose, duty cycle, and frequency. • Training is dependent on the individual. Nationwide representatives available for training needs. • Portable • Two-year warranty • Purchase directly or through a distributor • Lease options • Billing reimbursement Dynatronics • 800-874-6251 www.dynatronics.com

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Pro Sport Package

The Pro Sport Package provides in-onefield treatment via portable unit and in-clinic care for accelerated pain relief and healing while optimizing performance. • Effective on Olympic, professional, collegiate, and recreational athletes • Easy to use with TARGET (Treatment Area Recognition and Guidance Enhanced Technology) to identify treatment area • Cost-effective • Hand-held and in-clinic units • Multi Radiance Medical offers NMS • Stimulation modes: Neuro-adaptive stimulator • One channel • Output voltage (peak to peak): 90-650 volts • Timer • Combination units available • Two-year warranty • Lease options • Billing reimbursement • Additional training recommended Multi Radiance Medical • 800-373-0955 www.multiradiance.com

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MR4 with LaserStim

MR4 with LaserStim allows for insurance reimbursement, identifies treatment areas via TARGET (Treatment Area Recognition and Guidance Enhanced Technology), is easy to use, and effectively reduces pain and accelerates healing. • Laser class: IIIB, EN60825-1M • FDA approval for pain, inflammation, arthritis, joint pain, and muscle spasms • Multi Radiance Medical covers 42 countries internationally and has been manufacturing lasers for over three decades • Portable and home devices available • Multiple wave lengths • Pulsing • Two-year warranty • Lease options • Billing reimbursement Multi Radiance Medical • 800-373-0955 www.multiradiance.com

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Dynatron Solaris 709

The Dynatron Solaris 709 offers ultrasound, seven stim waveforms, and the option of adding light therapy. • 14.32” x 4.6” x 12.7” • 13 pounds • 100-240 volt power supply/optional battery pack • Five channels (four, plus a dedicated high-voltage channel) • Modes: interferential/premodulated; biphasic/Russian; high-voltage; microcurrent; direct current; ultrasound; light; combination; and stimulation treatments • Output voltage (peak to peak): 1-130 volts (interferential); 0-300 volts (high-voltage); 0-12 (other stim modalities) • Timer included • Hands-free and hands-on operation • Nationwide representatives available for training needs Dynatronics • 800-874-6251 www.dynatronics.com

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Web News Searchable Library of Healthcare

Hygenic/Performance Health’s Web sites align with the company’s market-leading brands, Thera-Band and Biofreeze, and their research initiatives. At the Thera-Band and Biofreeze sites, visitors will find product specifications, educational resources, FAQs, and testimonials. These sites also feature a “Where to Buy” locator tool that enables consumers to easily find healthcare professionals who sell Biofreeze and Thera-Band products—solutions that help athletes manage pain, improve strength, and restore function. The Thera-Band Academy’s Web site is a free resource designed to provide a large, searchable library of research, evidenced-based protocols, and exercise instructions for healthcare professionals and consumers.

www.biofreeze.com • www.thera-band.com www.thera-bandacademy.com

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Company Q&A

Ankle Injuries: How Can Bracing Help A conversation with Stephen Paulseth Stephen Paulseth, PT, DPT, SCS, and ATC, is head of the Paulseth & Associates Physical Therapy clinics in Los Angeles, specializing in physical therapy services for elite athletes, Olympians, and amateur athletes, and is Board Certified as a Sports Clinical Specialist. He is the Past-President of the Foot and Ankle Special Interest Group of the American Physical Therapy Association (APTA), and served on the United States Olympic Committee’s sports medicine delegation for the 2004 Olympic Games in Athens, and with the Federation Internationale de Volleyball (FIVB) beach volleyball world tour.

How frequently do athletes suffer ankle injuries? Paulseth: The ankle accounts for 10-25 percent of all injuries in sports, especially the lateral (outside) ligaments, which are injured 85 percent of the time during an ankle sprain. Of these injuries, 10 to 40 percent become recurrent and can produce ankle instability. Wearing a brace like the ZAMST A-1 or FA1 will provide athletes with moderate protection on a daily basis and help with their overall injury prevention plan.

How severe can ankle injuries become? Ankle sprains are categorized according to their severity from Grade I to III. A first-degree lateral ankle sprain includes mild pain and swelling, localized tenderness on the front and outside of the ankle, and an ability to ambulate. A second-degree lateral ankle sprain includes moderate pain and swelling with discoloration present, pain with ambulation, moderate lateral ankle instability, and partial tearing of the anterior talofibular ligament. A third-degree lateral ankle sprain typically occurs after an athlete hears a “pop” with immediate pain and swelling. The athlete is unable to bear weight, and there is severe lateral ankle instability, with total disruption of the lateral ligaments. The individual loses control of the position of his or her foot and ankle, which is also known as “proprioception.” This is especially true after repetitive ankle sprains and those that go untreated or unsupported when the athlete returns to sports. In this case, we recommend the ZAMST A2-DX ankle brace, which will provide stability, but will also allow natural

movement and flexibility of the ankle during the rehabilitation process, promoting recovery and strengthening of the ankle.

What can an athlete do to reduce the occurrence of an ankle injury? Using an ankle brace has been proven to reduce the occurrence and/or severity of ankle injury. ZAMST has a wide range of ankle supports to meet different needs for different athletes. Prevention of ankle sprains is obviously the place to start for an athlete, in particular for those who play volleyball, basketball, and most court sports. Athletes should pay attention to their body’s warning signs to slow down when they feel pain or fatigue. Once an injury has occurred, protecting the involved ankle with bracing or strapping should be followed. If the patient has repeated sprains, wearing an ankle brace while playing has been proven useful.

What has the reaction been to the ZAMST line of ankle braces? The athletes wearing the braces have a very positive reaction to the ZAMST fit. They call it “3-D” because the design of each ZAMST ankle brace allows users to adjust each part of the brace to reach a perfect fit. It is important for the ankle brace to fit properly in order to do the job right. ZAMST ankle braces are not “one size fits all” because they are adjustable, durable, and made of breathable, flexible materials that are also washable. Athletes who have worn braces before like the fact that the ZAMST braces provide protection, but also allow for natural movement of the ankle. The athletes who have not worn braces before can adjust more easily to ZAMST, because of the light, breathable materials that do not feel bulky around the ankle, or in the athletic footwear.

3495 Piedmont Rd., Bldg. 11, Ste. 710, Atlanta, GA 30305 www.zamst.com TR AINING-CONDITIONING.COM

877-ZAMST-US (877-926-7887)

T&C DECEMBER 2010